Job Title: Investigator Senior
Job Responsibilities:
- Conduct independent identification, investigation, and development of complex cases against perpetrators of healthcare fraud.
- Recover corporate and client funds paid on fraudulent claims.
- Perform claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Identify and develop enterprise-wide specific 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 policy and/or procedures to prevent the loss of company assets.
- Represent the company in court proceedings regarding research findings.
- Develop and maintain 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:
- Requires a BA/BS and a minimum of 5 years of related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience that would provide an equivalent background.
- Preferred qualifications include professional certification of CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designation.
- 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.
- The salary offered is based on various legitimate, non-discriminatory factors as determined by the company.
- **Members Only** offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution, subject to eligibility requirements.
- The salary range is an estimate of possible compensation and may be modified in the future. Actual compensation will vary based on geographic location, work experience, education, skill level, and market/business considerations.
Company Information:
- **Members Only** is a health company dedicated to improving lives and communities and simplifying healthcare. It is a Fortune 25 company with a longstanding history in the healthcare industry.
- The company is committed to creating a culture that promotes personal and professional growth for its associates and values diversity and inclusion.
- **Members Only** operates under a Hybrid Workforce Strategy, requiring associates to work at a company location at least once per week unless specified as primarily virtual.
- The company requires candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza, following all relevant federal, state, and local laws.
- **Members Only** is an Equal Employment Opportunity employer, considering all qualified applicants without regard to various protected statuses and conditions. Accommodations for the job application process are available upon request.
