Job Title: Investigator Senior
Job Responsibilities:
The Investigator Senior at the company is tasked with identifying, investigating, and developing complex cases against those perpetrating healthcare fraud, with the aim of recovering corporate and client funds paid on fraudulent claims. Key responsibilities include:
- Conducting claim reviews for appropriate coding, data mining, and entity review.
- Making law enforcement referrals and utilizing proprietary data and claim systems for reviewing 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 within the enterprise.
- Interfacing internally with senior-level management and the legal department throughout the investigative process.
- Assisting in training internal and external entities.
- Contributing to the development of policies and procedures to prevent the loss of company assets.
- Potentially 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 and healthcare insurance investigation or law enforcement. Alternatively, any combination of education and experience that provides an equivalent background will be considered.
Preferred Skills, Capabilities, and Experiences include:
- Professional certification such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designations.
- Experience with Excel.
- Experience with medical records is considered a plus.
Salary Information:
The job description does not provide specific salary information. However, it mentions that the company offers a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical, dental, vision, short and long-term disability benefits, 401(k) with match, stock purchase plan, life insurance, wellness programs, and financial education resources.
Additional Information:
The role involves a hybrid work strategy, requiring associates to be in the office 1-2 days per week to foster collaboration and connectivity while supporting productivity and work-life balance. **Members Only** requires all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza, with exceptions only for acceptable explanations. The company is committed to Equal Employment Opportunity and encourages applications from all qualified individuals regardless of various protected statuses.
**Members Only** emphasizes creating a culture that supports personal and professional growth for its associates, with values and behaviors that drive business outcomes and shared success. The company is part of the Fortune 25 and has a longstanding history in the healthcare industry, dedicated to improving lives and communities and simplifying healthcare.
