Legal Staff Paralegal in Nashville, TN

In-House

Nashville, TN

Legal Staff Paralegal in Nashville, TN

Legal Staff

Min 5 yrs required

No

Investigator Senior - Job Summary:

- Investigator Senior role within the Payment Integrity line of business
- Location: Hybrid model (remote and office) with alternate locations considered
- Must live within 50 miles of a PulsePoint location
- Part of the **MEMBERS ONLY**SIGN UP NOW***. family of companies
- Recover, eliminate, and prevent unnecessary medical-expense spending
- Responsible for identifying, investigating, and developing complex cases of healthcare fraud
- Recover corporate and client funds paid on fraudulent claims
- Requires health insurance experience and understanding of policies, claims handling, and provider network contracting
- Conduct claim reviews for appropriate coding, data mining, entity review, and law enforcement referral
- Utilize proprietary data and claim systems for facility, professional, and pharmacy claims review
- Independently identify and develop healthcare investigations and initiatives that may impact more than one company health plan, line of business, and/or state
- May interface with senior level management and legal department throughout investigative process
- Assist in training internal and external entities
- Develop and maintain rapport with law enforcement and regulatory agencies
- Requires a BA/BS and minimum of 5 years related experience in healthcare insurance and investigation, law enforcement, or equivalent combination of education and experience
- Professional certification preferred (CFE, AHFI, CPC, Paralegal, RN, JD)
- Knowledge of plan policies and procedures with emphasis on negotiation preferred
- **MEMBERS ONLY**SIGN UP NOW***. only accepts resumes for compensation from agencies with a signed agreement
- Fortune 25 company with a longstanding history in the healthcare industry
- Creating a culture focused on personal and professional growth
- Market-competitive total rewards package
- Hybrid Workforce Strategy with onsite work requirements
- Vaccination against COVID-19 and Influenza required for certain patient/member-facing roles
- Equal Employment Opportunity employer
- Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.