About 1199SEIU Funds

1199SEIU Funds provides health, pension, training, and benefit services to members of the 1199SEIU healthcare workers union. The organization supports healthcare employees and their families through comprehensive benefits programs while promoting high standards of care, accountability, and service excellence. Through its various funds and programs, 1199SEIU Funds serves one of the largest healthcare worker populations in the United States.

The Role

The Senior Fraud Investigator is responsible for conducting complex investigations involving allegations of fraud, waste, and abuse (FWA) within healthcare claims and benefits programs. This role manages investigations from initial assessment through final resolution, utilizing data analysis, medical record reviews, coding audits, and investigative techniques to identify fraudulent activities and recover improper payments.

Working in a hybrid environment based in Midtown Manhattan, the successful candidate will collaborate with internal stakeholders, healthcare providers, attorneys, regulatory agencies, and law enforcement personnel to ensure the integrity of healthcare benefit programs.

Key Responsibilities

Fraud Investigation and Case Management

• Conduct investigations into allegations of fraud, waste, and abuse from intake through resolution
• Perform preliminary assessments and full-scale investigations
• Review medical records, claims data, enrollment information, and supporting documentation
• Prepare detailed investigative reports that document findings and recommendations
• Recommend interventions to mitigate risk and prevent future losses
• Pursue recovery of overpayments and support settlement negotiations when appropriate

Data Analysis and Compliance Reviews

• Analyze claims data using advanced data mining techniques to identify suspicious billing patterns and anomalies
• Conduct coding, billing, reimbursement, and medical necessity reviews
• Evaluate claims using CPT, HCPCS, ICD-9/10, DRG, and related coding standards
• Document findings and maintain accurate investigative records
• Monitor compliance with healthcare regulations and industry standards

Stakeholder Collaboration and Communication

• Coordinate with internal departments to obtain documentation and evidence
• Communicate with physicians, healthcare providers, attorneys, regulatory agencies, and law enforcement personnel
• Support settlement discussions with providers and legal representatives
• Present findings clearly through written reports and verbal communications
• Maintain confidentiality and professionalism throughout all investigations

Regulatory Compliance

• Ensure compliance with HIPAA and PHI requirements
• Follow organizational policies and procedures regarding investigations and data security
• Maintain confidentiality of sensitive information and investigative findings

Requirements

• Bachelor’s degree in business, criminal justice, or a related field
• Minimum three years of experience reviewing medical records and medical coding
• Minimum three years of experience within a healthcare Special Investigations Unit (SIU) or a government agency investigating healthcare fraud
• Strong knowledge of medical coding, medical terminology, and healthcare reimbursement processes
• Experience conducting fraud investigations and recovering overpayments
• Strong analytical and data interpretation skills
• Excellent report writing and documentation abilities
• Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook
• Excellent verbal, written, and interpersonal communication skills

Preferred Qualifications

• Certified Professional Coder (CPC)
• Accredited Healthcare Fraud Investigator (AHFI)
• Certified Insurance Fraud Investigator (CIFI)
• Certified Economic Crime Forensic Examiner (CECFE)
• Experience using STARSSolutions or other healthcare fraud detection and case management software

What They Offer

• Hybrid work arrangement with office attendance in Midtown Manhattan
• Opportunity to work on complex healthcare fraud investigations
• Exposure to healthcare compliance, regulatory, and law enforcement environments
• Collaborative work environment with internal and external stakeholders
• Professional growth opportunities within a leading healthcare benefits organization

How to Apply

Interested candidates should submit their application through the 1199SEIU Funds recruitment portal and provide all required supporting materials. Applicants should highlight their experience in healthcare fraud investigations, medical coding, claims analysis, and regulatory compliance, as well as any relevant certifications related to healthcare fraud examination or medical coding.