Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
If you’re an EmblemHealth employee, unlock your career potential by signing in at the top of this page. Access your employee profile to view internal job postings and explore new opportunities.
Senior Investigator - Hybrid/Remote Possible
- 📁
- 💼
- EmblemHealth
- 📅
- Feb 27, 2026 Post Date
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 records 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)
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, Emblemhealth may provide work visa sponsorship for certain positions.