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 role is integral to supporting the Payment Integrity line of business at the company. The primary responsibility is the independent identification, investigation, and development of complex cases against healthcare fraud perpetrators to recover corporate and client funds paid on fraudulent claims. Key duties include:

- Conducting claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and utilizing proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business, or state.
- Interfacing internally with senior-level management and the legal department throughout the investigative process.
- Assisting in training internal and external entities.
- Developing policies and/or procedures to prevent the loss of company assets.
- Representing the company in court proceedings regarding research findings.
- Building and 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 minimum requirements for the Investigator Senior position include:

- A Bachelor’s degree (BA/BS) and a minimum of five 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 is acceptable.

Preferred qualifications, skills, and capabilities include:

- 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 programs management, with a heavy emphasis on negotiation, is also preferred.

Salary Information:
For candidates working in specified locations, including California, Colorado, District of Columbia (Washington, DC), Maryland, Minnesota, New York, and Washington State, the salary range for the Investigator Senior 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. All benefits are subject to eligibility requirements.

The salary offered for this position is based on legitimate, non-discriminatory factors set by the company and 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. Compensation within the range may vary based on geographic location, work experience, education, skill level, and market/business considerations. Bonuses, commissions, and other benefits are at the company’s discretion and may be modified as per company policies and legal requirements.