Corporate Compliance Investigator

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

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 reports to the Manager Corporate Compliance. The Corporate Compliance Investigator will support the oversight and management of Corporate Compliance activities, including addressing and tracking inquires, 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).

Job Description

• Responsible for the initial screening, timely investigation, and triaging of compliance matters, including allegations of fraud, waste, and abuse. Ensuring a thorough and comprehensive investigation of the alleged compliance violation is performed, including the collection of documentation and/or evidence, data analyses and interviews.
• Perform review and assessment of coding on claims data and medical documentation to ensure its accuracy, as it relates to 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.
• Creating, reviewing, and submitting 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 Fraud, Waste and Abuse Committee, Compliance Committee, and Audit and Compliance Committee of the Board of Directors.
• Drafting, submitting and tracking referrals of substantiated or suspicious fraud, waste and abuse cases to regulators.
• Reviewing Centers for Medicare and Medicaid ("CMS") Health Plan Management System ("HPMS") Memos from the Fraud Investigations Group and ensuring that internal business areas are taking action, when required.
• Collaborate with business areas to ensure that appropriate disciplinary and corrective actions are initiated and completed.
• Assist in managing our relationship with the Special Investigations Unit, including active participation in monthly meetings, ensuring ongoing collaboration, and identifying opportunities for improvement.
• Assist in the development of the annual risk assessment and implementation of the annual work plan.
• 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

• Bachelor's Degree required; and
• 5 years of experience in a compliance, privacy, regulatory affairs, grievance & appeals, or government affairs function within a managed care organization; or
• A satisfactory equivalent combination of education, training, and experience.
• Master's Degree preferred
• 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 metric.
• 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.

Professional Competencies

• Proficient skill in Microsoft products, including Excel, Word, PowerPoint, Vizio.
• Broad-based in-depth knowledge of the managed care industry, including: strategic compliance planning, regulatory concerns, compliance requirements, and corporate integrity principles.
• The ability to comprehend and interpret regulatory, legislative, and contractual mandates.
• High-level of skill in leading interdepartmental and cross-functional projects; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met.
• Excellent oral, written, and presentation skills, state as well as conceptual and analytic skills are necessary to review and articulate corporate objectives and Federal regulations across all relevant audiences.
• The utmost integrity in the discreet and confidential handling of confidential materials is necessary.

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