Job Title: Investigator Senior
Job Responsibilities:
- Independently identify, investigate, and develop complex cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims.
- Conduct claim reviews for appropriate coding, data mining, entity review, and law enforcement referral.
- Utilize proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Develop enterprise-wide specific healthcare investigations and initiatives impacting multiple company health plans, lines of business, and/or states.
- Interface internally with senior-level management and the legal department throughout the investigative process.
- Assist in training internal and external entities.
- Assist in the development of policies and/or procedures to prevent loss of company assets.
- Represent the company in court proceedings regarding research findings.
- Maintain a high degree of rapport and cooperation with Federal, State, and local law enforcement and regulatory agencies to aid in investigative efforts.
Education and Experience Information:
- Requires a BA/BS degree.
- Minimum of 5 years of related experience in healthcare insurance, healthcare insurance investigation, or law enforcement.
- A combination of education and experience that provides an equivalent background is acceptable.
Preferred Qualifications, Skills & Capabilities:
- Professional certification such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designations preferred.
- Knowledge of plan policies and procedures in all facets of benefit programs management with a strong emphasis on negotiation is preferred.
Salary Information:
- The salary range for this position is $78,400 to $141,120 for candidates working in California, Colorado, District of Columbia, Maryland, Minnesota, New York, and Washington State.
- **Members Only** offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution, subject to eligibility requirements.
- The salary offered is based on legitimate, non-discriminatory factors set by the company, ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
- Actual compensation may vary based on geographic location, work experience, education, skill level, and market/business considerations. Compensation is subject to modification and is not considered wages until earned, vested, and determinable under applicable policies and plans.
Company Overview:
**Members Only** is a health company dedicated to improving lives and communities, aiming to simplify healthcare. As a Fortune 25 company with a longstanding history in the healthcare industry, **Members Only** seeks leaders passionate about making an impact on its members and the communities it serves.
Work Culture and Benefits:
- **Members Only** fosters a culture designed for personal and professional growth, based on core values and behaviors.
- Offers 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) match, stock purchase plan, life insurance, wellness programs, and financial education resources.
- Operates in a Hybrid Workforce Strategy, requiring associates to work at an **Members Only** location at least once per week unless specified as primarily virtual.
- Requires vaccination against COVID-19 and Influenza for certain patient/member-facing roles, with exceptions considered.
- Complies with all relevant federal, state, and local laws regarding Equal Employment Opportunity and fair chance employment practices.
Application and Accommodation Information:
- **Members Only** only accepts resumes from agencies with a signed agreement.
- Applicants requiring accommodation for the application process may contact the provided support email for assistance.
- Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws, including ordinances and acts specific to certain jurisdictions.
