Attorney in Costa Mesa, CA

In-House

Costa Mesa, CA

Attorney in Costa Mesa, CA

Non-practicing Attorney

Min 5 yrs required

No

Job Title: Investigator Senior

Job Responsibilities:
The Investigator Senior is tasked with independently identifying, investigating, and developing complex cases against individuals involved in healthcare fraud to recover funds for the company and its clients. Key responsibilities include:

- Conducting claim reviews for appropriate coding, data mining, entity review, and law enforcement referral.
- 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 company health plans, lines of business, and/or states.
- Interfacing internally 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.
- Representing the company in court proceedings related to research findings.
- Developing and maintaining a strong rapport with federal, state, and local law enforcement and regulatory agencies to aid in investigative efforts.

Education and Experience Information:
The position requires a BA/BS degree and a minimum of five years of related experience in healthcare insurance, healthcare insurance investigation, or law enforcement. Alternatively, an equivalent combination of education and experience may be considered suitable for the role.

Preferred Qualifications, Skills & Capabilities:
- Professional certification such as CFE (Certified Fraud Examiner), AHFI (Accredited Healthcare Fraud Investigator), CPC (Certified Professional Coder), Paralegal, RN (Registered Nurse), JD (Juris Doctor), or other relevant designations are preferred.
- Knowledge of plan policies and procedures in all aspects of benefit programs management, with a strong emphasis on negotiation, is preferred.

Salary Information:
For candidates working in specified locations, the salary range for this position is $78,400 to $141,120. These locations include California, Colorado, District of Columbia (Washington, DC), Maryland, Minnesota, New York, and Washington State.

In addition to salary, the company offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution. The salary offered is based on legitimate, non-discriminatory factors set by the company and is subject to eligibility requirements. The company is committed to ensuring equal pay opportunities for equal work, regardless of gender, race, or any other protected category under federal, state, and local pay equity laws.

The salary range reflects the company's good faith belief in the possible compensation for this role at the time of posting and may be modified in the future. Actual compensation may vary based on geographic location, work experience, education, and skill level. Additionally, the availability of bonuses, commissions, benefits, or any other form of compensation is at the company's sole discretion unless paid and may be modified consistent with the law.

Company Overview:
The company is dedicated to improving lives and communities by simplifying healthcare. As a Fortune 25 company with a longstanding history in the healthcare industry, the company seeks leaders passionate about making an impact on its members and the communities it serves. The company operates under a Hybrid Workforce Strategy, requiring associates to work on-site at least once per week unless specified as primarily virtual by the hiring manager. The health of associates and communities is a top priority, with vaccination requirements in place for certain roles.

The company is an Equal Employment Opportunity employer, offering consideration for employment regardless of age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other protected status under applicable laws. Applicants needing accommodation for the job application process may contact the company for assistance. The company considers applicants with arrest or conviction records for employment in accordance with relevant laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.