Attorney in Atlanta, GA

In-House

Atlanta, GA

Attorney in Atlanta, GA

Non-practicing Attorney

Min 5 yrs required

No

Job Title: Investigator Senior

Job Responsibilities:

- Independently identify, investigate, and develop complex cases against healthcare fraud perpetrators to recover funds for the company and its clients.
- Conduct claim reviews for appropriate coding, data mining, entity review, law enforcement referrals, and utilize proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Develop enterprise-wide healthcare investigations and initiatives that may impact 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.
- Contribute to the development of policies and procedures aimed at preventing the loss of company assets.
- May represent the company in court proceedings regarding research findings.
- Cultivate and maintain a high degree of rapport and cooperation with federal, state, and local law enforcement and regulatory agencies to support investigative efforts.

Education and Experience Information:

- 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 Qualifications, Skills & Capabilities:

- Professional certifications such as CFE (Certified Fraud Examiner), AHFI (Accredited Health Care Fraud Investigator), CPC (Certified Professional Coder), Paralegal, RN (Registered Nurse), JD (Juris Doctor), or other job-related designations are preferred.
- Knowledge of plan policies and procedures in all facets of benefit program management, with a strong emphasis on negotiation, is preferred.

Salary Information:

- For candidates working in specified locations (California, Colorado, District of Columbia, Maryland, Minnesota, New York, Washington State), the salary range for this position is $78,400 to $141,120.
- **Members Only** offers additional benefits, including a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution. All benefits are subject to eligibility requirements.
- The salary offered is based on several legitimate, non-discriminatory factors set by the company, which is committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by pay equity laws.
- The salary range reflects what **Members Only** believes to be the possible compensation range for this role at the time of posting. This range may change in the future, and actual compensation may vary based on factors such as geographic location, work experience, education, and skill level.
- No amount is considered wages or compensation until it is earned, vested, and determinable under the applicable policies and plans. The availability and amount of any bonus, commission, benefits, or other forms of compensation and benefits are at the company's discretion until paid.

Additional Information:

- **Members Only** only accepts resumes for compensation from agencies with signed agreements. Unsolicited resumes are considered the property of **Members Only**.
- **Members Only** is a Fortune 25 health company dedicated to improving lives and simplifying healthcare. The company seeks leaders passionate about impacting members and communities.
- **Members Only** 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) +match, stock purchase plan, life insurance, wellness programs, and financial education resources.
- **Members Only** operates under a Hybrid Workforce Strategy, requiring associates to work at an **Members Only** location at least once a week unless specified as primarily virtual.
- New candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza, with exceptions considered.
- **Members Only** is an Equal Employment Opportunity employer and considers all qualified applicants without regard to various protected statuses. Applicants requiring accommodation for the application process may contact the company for assistance.
- Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Jun 26, 2025
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