Investigator Senior
Job Title:
Investigator Senior
Job Responsibilities:
The Investigator Senior is tasked with the independent identification, investigation, and development of complex cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims. The primary responsibilities include:
- Conducting claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and utilizing proprietary data and claim systems for the examination of facility, professional, and pharmacy claims.
- Independently identifying and developing healthcare investigations and initiatives that may impact multiple health plans, lines of business, and/or states.
- Potentially interfacing with senior-level management and the legal department throughout the investigative process.
- Assisting in the training of internal and external entities.
- Contributing to the development of policies and/or procedures to prevent the loss of company assets.
- Possibly representing the company in court proceedings regarding research findings.
- Maintaining a high degree of rapport and cooperation with federal, state, and local law enforcement and regulatory agencies to assist in investigative efforts.
Education and Experience Information:
The position requires a BA/BS degree and a minimum of 5 years of related experience in healthcare insurance, healthcare insurance investigation, or law enforcement. Alternatively, a combination of education and experience that provides an equivalent background is acceptable.
Preferred Skills, Capabilities, and Experiences:
- Professional certification such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designations are preferred.
- Experience with Excel is preferred.
- Experience with medical records is a plus.
Salary Information:
The text does not provide specific salary information. However, it mentions that **Members Only** offers a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.
Additional Information:
The Investigator Senior position is part of a hybrid work model, requiring associates to be in-office 1-2 days per week to foster collaboration and connectivity while providing flexibility for productivity and work-life balance. **Members Only** operates with a Hybrid Workforce Strategy, and unless specified as primarily virtual, associates must work at an **Members Only** location at least once per week. Specific onsite requirements and expectations will be discussed during the hiring process.
**Members Only** emphasizes the health of associates and communities, requiring new candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza unless a valid explanation is provided. The company follows relevant federal, state, and local laws regarding health and safety regulations.
**Members Only** is committed to Equal Employment Opportunity and considers all qualified applicants without regard to various protected statuses, ensuring a fair and inclusive hiring process. Applicants requiring accommodation during the job application process can reach out for assistance, and those with arrest or conviction records will be considered for employment in line with applicable laws.
Company Overview:
**Members Only** is a health company dedicated to improving lives and communities while simplifying healthcare. As a Fortune 25 company with a longstanding history in the healthcare industry, **Members Only** seeks leaders at all levels who are passionate about making an impact on members and communities. The company fosters a culture designed to advance its strategy, leading to personal and professional growth for associates.
