Attorney in Richmond, VA

In-House

Richmond, VA

Attorney in Richmond, VA

Non-practicing Attorney

Min 5 yrs required

No

Job Title: Investigator Senior

Job Responsibilities:
The Investigator Senior plays a crucial role in the Payment Integrity line of business by independently identifying, investigating, and developing complex cases against perpetrators of healthcare fraud. This position aims to recover corporate and client funds paid on fraudulent claims. Key responsibilities include:
- Conducting claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and using proprietary data and claim systems for facility, professional, and pharmacy claims.
- Independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business, and/or state.
- Interfacing internally with Senior level management and the legal department throughout the investigative process.
- Assisting in training internal and external entities.
- Contributing to the development of policies and procedures to prevent the loss of company assets.
- Representing the Company in court proceedings regarding research findings.
- Developing 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 position requires a degree and a minimum of 5 years of related experience in healthcare insurance and healthcare insurance investigation or law enforcement. Alternatively, a combination of education and experience that provides an equivalent background is acceptable. Preferred qualifications include professional certifications such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), Certified Professional Coder (CPC), Paralegal, Registered Nurse (RN), Juris Doctor (JD), or other job-related designations. Knowledge of plan policies and procedures in all facets of benefit programs management, particularly in negotiation, is preferred.

Salary Information:
For candidates working in person or virtually in specific locations including California, Colorado, District of Columbia, Maryland, Minnesota, New York, and Washington State, the salary range for this position is $78,400 to $141,120. In addition to the salary, **Members Only** offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution, all subject to eligibility requirements. The salary offered is based on several legitimate, non-discriminatory factors set by the Company, ensuring equal pay opportunities for equal work regardless of gender, race, or other protected categories by federal, state, and local pay equity laws.

Note: The salary range is the range **Members Only** believes is possible compensation for this role at the time of this posting. This range may be modified in the future, and actual compensation may vary based on geographic location, work experience, education, and/or skill level. The availability of any bonus, commission, benefits, or any other form of compensation and benefits remains at the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Additional Information:
**Members Only** is committed to creating a culture that promotes personal and professional growth for its associates. The company operates under a Hybrid Workforce Strategy, requiring associates to work at an **Members Only** location at least once per week unless specified otherwise. The health of associates and communities is a priority, requiring new candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided. **Members Only** complies with all relevant federal, state, and local laws. The company is an Equal Employment Opportunity employer, and qualified applicants will receive consideration for employment without regard to various protected statuses. Applicants requiring accommodation during the job application process may contact the company for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.