Attorney in Miami, FL

2 views

In-House

Miami, FL

Attorney in Miami, FL

Non-practicing Attorney

Min 5 yrs required

No

Job Title: Investigator Senior

Job Responsibilities:
The Investigator Senior plays a critical role in supporting the Payment Integrity line of business within the company. This position is responsible for independently identifying, investigating, and developing complex cases against individuals or entities involved in healthcare fraud. The primary goal is to recover corporate and client funds that have been paid out on fraudulent claims. Key responsibilities include:

- Conducting claim reviews to ensure appropriate coding, engaging in data mining, and performing entity reviews.
- Making referrals to law enforcement and utilizing proprietary data and claims systems to review facility, professional, and pharmacy claims.
- Independently identifying and developing healthcare investigations and initiatives that may impact multiple health plans, lines of business, or states.
- Interfacing with senior-level management and the legal department during the investigative process.
- Assisting in the training of internal and external entities.
- Contributing to the development of policies and procedures aimed at preventing the loss of company assets.
- Representing the company in court proceedings related to research findings.
- Building and maintaining strong relationships with federal, state, and local law enforcement and regulatory agencies to aid in investigative efforts.

Education and Experience Information:
The position requires a Bachelor’s degree (BA/BS) and a minimum of 5 years of relevant 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 include:

- Professional certifications such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Paralegal, Registered Nurse (RN), Juris Doctor (JD), or other relevant designations.
- A comprehensive understanding of plan policies and procedures, particularly in benefit program management with a strong emphasis on negotiation.

Salary Information:
For candidates working in California, Colorado, District of Columbia, Maryland, Minnesota, New York, and Washington State, the salary range for the Investigator Senior position is $82,320 to $141,120. **Members Only** offers a comprehensive benefits package, including incentive and recognition programs, equity stock purchase, and 401k contributions, subject to eligibility requirements. The salary offered is based on various legitimate, non-discriminatory factors such as geographic location, work experience, education, and skill level. The company is committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other protected category by federal, state, and local pay equity laws.

Company Overview:
**Members Only** is a healthcare company dedicated to improving lives and communities while simplifying healthcare. As a Fortune 25 company with a long-standing history in the healthcare industry, **Members Only** seeks leaders at all organizational levels who are passionate about making a positive impact on members and the communities served. The company fosters a culture of personal and professional growth for its associates, driven by shared values and behaviors that power business outcomes and drive success for consumers, associates, communities, and the business itself.

How We Work:
**Members Only** operates under a Hybrid Workforce Strategy. Unless specified as primarily virtual, associates are required to work at an **Members Only** location at least once per week, with specific requirements and expectations discussed during the hiring process. The health of associates and communities is a top priority, and vaccination against COVID-19 and Influenza is required for new candidates in certain patient/member-facing roles. **Members Only** is committed to equal employment opportunities and considers all qualified applicants without regard to various protected statuses.

This summary provides a comprehensive overview of the Investigator Senior position, including job responsibilities, education and experience requirements, salary information, and company culture, which are essential for candidates considering this role.

Jun 18, 2025
Apply for this Attorney in Miami, FL job

Upload Resume:

Apply Later
Email   |   Print

The #1 legal job board in the United States year after year!

Tell us where to send your access instructions:

paywall sign up popp