Job Title: Investigator Senior
Job Responsibilities:
- The Investigator Senior supports the Payment Integrity line of business by independently identifying, investigating, and developing complex cases against healthcare fraud perpetrators to recover corporate and client funds paid on fraudulent claims.
- Conducts claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and utilizes proprietary data and claim systems for reviewing facility, professional, and pharmacy claims.
- Responsible for developing enterprise-wide specific healthcare investigations and initiatives that may affect multiple company health plans, lines of business, and/or states.
- Interfaces internally with senior-level management and the legal department throughout the investigative process.
- Assists in the training of internal and external entities and in the development of policy and/or procedures to prevent the loss of company assets.
- May represent the company in court proceedings regarding research findings.
- Develops and maintains 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 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 be considered.
- Preferred qualifications include professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designations.
- 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 specific locations, the salary range for this position is $78,400 to $141,120.
- Locations include California, Colorado, District of Columbia (Washington, DC), Maryland, Minnesota, New York, and Washington State.
- In addition to the salary, **Members Only** offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution.
- The salary offered is based on several 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 protected category.
- The salary range is the range **Members Only** believes is possible compensation for this role at the time of posting and may be modified in the future. Actual compensation may vary based on geographic location, work experience, education, and/or skill level. The actual compensation will also vary depending on 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.
- **Members Only** is creating a culture designed to advance its strategy and lead to personal and professional growth for its associates, with values and behaviors that drive success for consumers, associates, communities, and the business.
- The company offers market-competitive total rewards that include 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.
Work Environment:
- **Members Only** operates in a Hybrid Workforce Strategy, with associates required to work at an **Members Only** location at least once per week unless specified as primarily virtual.
- Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
- The health of associates and communities is a top priority, and new candidates in certain patient/member-facing roles are required to be vaccinated against COVID-19 and Influenza, subject to legal requirements.
Equal Employment Opportunity:
- **Members Only** is an Equal Employment Opportunity employer, providing consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other protected status or condition.
- Applicants requiring accommodation to participate in the job application process may contact the company's support 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.
