Corporate Compliance Investigator

Corporate Compliance Investigator

Job Ref : TE0033

Category : Compliance and Regulatory

Department : MHP CORPORATE COMPLIANCE

Location : 50 Water Street, 7th Floor,

New York,

NY 10004

Job Type : Regular

Employment Type : Full-Time

Work Arrangement : Hybrid

Salary Range : $95,000.00 - $103,250.00

Position Overview

Empower. Unite. Care.

MetroPlusHealth 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 Corporate Compliance 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).

This position will be required to operate within the office on an as-needed basis.

Duties & Responsibilities

• 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.

Minimum Qualifications

Professional Competencies

#LI-HYBRID

#MPH-50