Senior Investigator - Hybrid/Remote Possible

Company: EmblemHealth
Location: New York City
Posted on: March 27, 2026

Job Description:

Job Description Summary of Job Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products. Develop and maintain relationships with law enforcement (HHS-OIG, FBI, DOJ), regulatory agencies (DFS, MEDIC, OMIG, MFCU) and with industry peers. Provide guidance to the Fraud Investigators on SIU investigations and issues. Assist with anti-fraud training sessions and public speaking engagements. Responsibilities Investigate complex cases of reported fraud involving the Company’s Medicaid healthcare product. Develop leads from various sources to review for suspect activity. Review claim files and develop action plans for the investigation. Conduct highly comprehensive interviews/interrogations with providers. Conduct medical record assessments, and CPT coding issues. Provide guidance and mentor to the Fraud Investigators. Answer and respond to SIU Fraud Hotline cases when assigned based on schedule. Triage complaints that come to the SIU and follow through on resolution. Participate in meetings with providers, attorneys, law enforcement on a case-by-case basis as needed. Attend training, conferences, webinars to keep up to date on current trends and schemes of Fraud, Waste & Abuse. May assist with fraud awareness training sessions and public speaking engagements. Establish and maintain relationships with law enforcement (HHS-OIG, FBI), regulatory agencies (i.e DFS, MEDIC, OMIG, MFCU, NYS OAG), and with industry peers. Refer cases to law enforcement or regulatory agencies as needed. Periodically meet with representatives from law enforcement and regulatory agencies to keep updated on current trends. Handle and respond to Requests for Information (RFI) from law enforcement and regulatory agencies. Perform other duties as directed, assigned, or required. Qualifications Bachelor’s degree in criminal justice or related field. AHFI and/or CFE certification (Preferred. 4 – 6 years of relevant, professional work experience (Required) Additional experience/specialized training may be considered in lieu of a bachelor’s degree (Required) Professional investigation experience in economic or insurance related matters (Required) Experience in insurance claims investigation or law enforcement (Preferred) Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options (Required) Proficiency in MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required) Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required) Attention to detail, critical thinking and problem-solving skills (Required) Ability to monitor and review information from materials, events, or the environment, to detect or assess problems (Required)

Keywords: EmblemHealth, Scranton , Senior Investigator - Hybrid/Remote Possible, Legal , New York City, Pennsylvania