Corporate Compliance Investigator

This range is provided by Metro Plus Health . Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$95,000.00/yr - $/yr

Empower. Unite. Care.

Metro Plus Health is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Corporate Compliance Investigator, who reports to the Manager of Corporate Compliance, will support the oversight and management of Corporate Compliance activities, including addressing and tracking inquiries and responding to all corporate compliance related questions. The Investigator is responsible for investigating allegations of potential fraud, waste, and abuse and reports of non-compliance. Allegations may include, but are not limited to, provider fraud (billing for services not rendered, drug diversion, providing unnecessary services to members), member fraud (identity theft, sharing of member identification cards, adding ineligible dependents onto the plan), and broker/sales agent misconduct (sale of non-existent policies, enrolling individuals without their consent, duplicate enrollments, and alteration of records).

• Responsible for the initial screening, triaging, and investigation of non-compliance issues, including allegations of fraud, waste, and abuse, that are reported internally or assigned by the Manager of Corporate Compliance, ensuring timely review and appropriate follow-up.
• Evaluate the accuracy of claims data and medical record documentation in connection with investigations of fraud, waste, and abuse.
• Prepare timely and concise final investigation reports. Essential to this role is the ability to track and trend emerging issues and work with the Manager to develop a response on an organizational level for systemic issues.
• Create, review, and submit internal and external reports as required. Will need to engage with leadership from various areas and vendors to compile information needed for response. Includes data submitted for the various committees in which Corporate Compliance participates, including the Compliance Committee, and Audit and Compliance Committee of the Board of Directors.
• Draft, submit and track referrals of substantiated or suspicious fraud, waste and abuse cases to regulators stemming from investigations.
• Collaborate with business areas to ensure that appropriate disciplinary and corrective actions are initiated and completed.
• Must remain abreast of emerging topics and issues impacting corporate compliance on the State and Federal level. If any changes impact the organization, must be able to work across departments to ensure proper implementation.
• Support the Manager of Corporate Compliance with any required regulatory reporting.
• Other duties as assigned or requested.

• Bachelor’s Degree required.
• 3 years of experience in a compliance, privacy, regulatory affairs, grievance & appeals, or government affairs function within a managed care organization.
• Coding certification or experience preferred.
• Understanding of claim billing codes, medical terminology, and health care delivery systems.
• Experience working with regulators on compliance audits, reporting and other matters.
• Experience managing complicated projects and staging work to deliver projects timely.
• Experience maintaining highly confidential and sensitive information.
• Experience with developing reporting and metrics.
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as the New York State of Health Marketplace.
• Proven ability to articulate regulatory requirements to business and technical staff to capture information and achieve results.
• Knowledge and experience in health care fraud, waste, and abuse investigations.
• Certified Healthcare Compliance (CHC), Certified Compliance & Ethics Professional (CCEP), or Certified Healthcare Privacy Compliance (CHPC) certificates are preferred.

• Proficient skill in Microsoft products, including…