Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The SIU Special Investigator will be responsible for investigating complex insurance cases to detect internal and external fraud and abuse. The Special Investigator will research and document cases utilizing resources available to identify suspicious billing patterns and trends. The Investigator will prepare case reports and documents as well as conduct interviews of providers, members, and person/persons with knowledge of the matter under investigation. They will assist in performing audits of providers’ claim submissions to assure that services rendered and billed correspond with members’ medical records. They are responsible for recognizing violations of CDPHP provider and/or member’ contracts/agreements, policies and procedures, and State and Federal laws pertaining to the health care industry. The Special Investigator will coordinate referrals of suspicious instances of fraud and abuse to state and federal agencies as well as assist with negotiating favorable financial settlements on behalf of CDPHP or in preparation of civil suit. The Special Investigator will take an active role in the training of CDPHP employees, providers, and members in the identification and remediation of fraud, waste, and abuse.

QUALIFICATIONS:

• Degree in Criminal Justice or related field preferred.

• Bachelor’s degree or four (4) years of equivalent experience required.

• Designation as an Accredited Health Care Fraud Investigator preferred.

• Incumbent must meet one of the minimum qualifications outlined below, in line with New York State requirements:

• Associate's or Bachelor's degree in criminal justice or related field, or

• Minimum five (5) years of insurance claims investigation experience or professional investigation experience with law enforcement agencies or

• Minimum seven (7) years of professional investigation experience involving economic or insurance related matters.

• Experience with CPT and ICD-9 coding used in health care benefits and claims processing required.

• Experience working with complex contracts with healthcare systems, large medical groups, hospitals, ancillary providers, individual practitioners, and members for Commercial, Medicare, and Medicaid lines of business required.

• Experience with payment methodologies required.

• Experience working with law enforcement, responding to subpoenas and/or testifying in Federal and State court proceedings preferred.

• Experience with Microsoft Office, including Word, Excel, Outlook, and PowerPoint is required, experience with Access preferred.

• Demonstrated ability to identify and determine fraudulent activity and compile necessary documentation in a clear concise manner.

• Demonstrated ability to analyze claims to determine correct processing.

• Demonstrated ability to present complex information in a digestible manner to both internal and external parties, including law enforcement and/or in court proceedings.

• Demonstrated knowledge of broker responsibilities and requirements.

• Demonstrated knowledge of payment methodologies.

• Demonstrated analytical, decision making, and problem-solving skills.

• Demonstrated ability to work collaboratively with multiple partners to positively affect outcomes at the team, organization, and member level.

• Must be detail-oriented with strong organizational skills, including the ability to coordinate workflow.

• Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.

• Demonstrated ability to work with and maintain confidential information.

CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.

CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at https://www.cdphp.com/about-us/jobs/benefits.

As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.