Attorney in Walnut Creek, CA

In-House

Walnut Creek, CA

Attorney in Walnut Creek, CA

Non-practicing Attorney

Min 5 yrs required

No

Job Title: Investigator Senior

Job Responsibilities:
The Investigator Senior at the company is tasked with independently identifying, investigating, and developing complex cases against perpetrators of healthcare fraud to recover funds paid on fraudulent claims. This role involves:

- Conducting claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and using proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one health plan, line of business, and/or state.
- Interfacing internally with senior-level management and the legal department during the investigative process.
- Assisting in training internal and external entities.
- Participating in the development of policies and/or procedures to prevent loss of company assets.
- 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 that can 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. An equivalent combination of education and experience may also be considered. Preferred qualifications include professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designations. Additionally, knowledge of plan policies and procedures in all facets of benefit program management with a heavy emphasis on negotiation is preferred.

Salary Information:
For candidates working in California, Colorado, District of Columbia (Washington, DC), Maryland, Minnesota, New York, and Washington State, the salary range for this position is $82,320 to $141,120. In addition to the salary, the company offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution, subject to eligibility requirements. The salary offered is based on a variety of legitimate, non-discriminatory factors set by the company. The company is committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

Additional Information:
The Investigator Senior role supports the Payment Integrity line of business and allows associates to work virtually full-time, with the exception of required in-person training sessions. This approach provides maximum flexibility and autonomy, promoting productivity and work-life integration. The company is a member of the **Members Only** family of companies, dedicated to improving lives and communities and making healthcare simpler. As a Fortune 25 company, it seeks leaders passionate about making an impact on members and the communities served.

The company offers a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical, dental, vision, disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources. The company operates in a Hybrid Workforce Strategy, requiring associates to work at a company location at least once per week unless specified as primarily virtual by the hiring manager.

The health and safety of associates and communities are a top priority, and new candidates in certain patient/member-facing roles are required to become vaccinated against COVID-19 and Influenza. **Members Only** is an Equal Employment Opportunity employer, considering all qualified applicants without regard to any status or condition protected by applicable laws. Applicants needing accommodation in the job application process may contact the company for assistance. Qualified applicants with arrest or conviction records will be considered for employment in compliance with federal, state, and local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.