Claims Integrity & Compliance Officer - Workers' Compensation Division

Claims Integrity & Compliance Officer - Workers' Compensation Division

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.

Minimum Qualifications

1. 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; or 2. An associate degree or 60 credits from an accredited college and six years of satisfactory full-time experience as described in "1" above; or 3. A four-year high school diploma or its educational equivalent and eight years of satisfactory experience as described in "1" above; or 4. Education and/or experience equivalent to "1", "2", or "3" above. However, all candidates must have the 18 months of experience in an administrative, managerial, executive or supervisory capacity as described in "1" above.

Preferred Skills

A baccalaureate degree from an accredited college and 4 years of satisfactory, responsible, full-time experience in fraud prevention, risk management, insurance fraud investigations, or a related field. Strong analytic, investigative, and communications skills are preferred. Experience in workers' compensation or insurance claims is a plus.

55a Program

This position is also open to qualified persons with a disability who are eligible for the 55-a Program. Please indicate at the top of your resume and cover letter that you would like to be considered for the position through the 55-a Program.

Public Service Loan Forgiveness

As a prospective employee of the City of New York, you may be eligible for federal loan forgiveness programs and state repayment assistance programs. For more information, please visit the U.S. Department of Education's website.

Residency Requirement

New York City residency is generally required within 90 days of appointment. However, City Employees in certain titles who have worked for the City for 2 continuous years may also be eligible to reside in Nassau, Suffolk, Putnam, Westchester, Rockland, or Orange County. To determine if the residency requirement applies to you, please discuss with the agency representative at the time of interview.

Additional Information

The City of New York is an inclusive equal opportunity employer committed to recruiting and retaining a diverse workforce and providing a work environment that is free from discrimination and harassment based upon any legally protected status or protected characteristic, including but not limited to an individual's sex, race, color, ethnicity, national origin, age, religion, disability, sexual orientation, veteran status, gender identity, or pregnancy.