Claims Integrity & Compliance Officer - Workers' Compensation Division

City of New York•New York City, NY

1d•Onsite

About The Position

Under the direction of the Deputy Division Chief, with wide latitude for independent initiative and judgment, the Claims Integrity & Compliance Officer (“CIIO” or “Officer”) is responsible for the development, implementation, and oversight of a comprehensive claims integrity and compliance program. This role encompasses operational oversight, regulatory compliance, and fraud detection and prevention. The Officer will analyze broad claims data to identify trends and anomalies, conduct targeted investigations into suspected fraudulent activity, and design proactive strategies to mitigate risk and ensure program integrity. The Claims Integrity & Compliance Officer will develop and deliver internal and external fraud prevention trainings and conduct or coordinate investigations to identify, detect, and prevent violations of applicable laws, rules, and regulations. In this capacity, the Officer will serve as the Division’s primary liaison to the New York City Department of Investigation and other oversight entities, ensuring coordination on matters related to fraud and compliance. Additional responsibilities include, but are not limited to, managing surveillance and investigative resources to validate entitlement to workers’ compensation benefits, identifying opportunities to improve operational efficiency and strengthen regulatory compliance, establishing and maintaining reporting mechanisms for employees and external parties to report suspected fraud, as well as the executing special projects and initiatives related to claims integrity, as assigned.

Requirements

A baccalaureate degree from an accredited college and four years of satisfactory full-time experience conducting investigations to identify or gather evidence of criminal activity or fraud, or to verify or evaluate qualifications of persons for employment or licensure, 18 months of which must have been in an administrative, managerial or executive capacity or supervising a staff performing investigations or related work.
An associate degree or 60 credits from an accredited college and six years of satisfactory full-time experience conducting investigations to identify or gather evidence of criminal activity or fraud, or to verify or evaluate qualifications of persons for employment or licensure.
A four-year high school diploma or its educational equivalent and eight years of satisfactory experience conducting investigations to identify or gather evidence of criminal activity or fraud, or to verify or evaluate qualifications of persons for employment or licensure.
Education and/or experience equivalent to the above.
Must have 18 months of experience in an administrative, managerial, executive or supervisory capacity conducting investigations to identify or gather evidence of criminal activity or fraud, or to verify or evaluate qualifications of persons for employment or licensure.

Responsibilities

Develop, implement, and oversee a comprehensive claims integrity and compliance program.
Analyze broad claims data to identify trends and anomalies.
Conduct targeted investigations into suspected fraudulent activity.
Design proactive strategies to mitigate risk and ensure program integrity.
Develop and deliver internal and external fraud prevention trainings.
Conduct or coordinate investigations to identify, detect, and prevent violations of applicable laws, rules, and regulations.
Serve as the Division’s primary liaison to the New York City Department of Investigation and other oversight entities.
Manage surveillance and investigative resources to validate entitlement to workers’ compensation benefits.
Identify opportunities to improve operational efficiency and strengthen regulatory compliance.
Establish and maintain reporting mechanisms for employees and external parties to report suspected fraud.
Execute special projects and initiatives related to claims integrity, as assigned.