Investigator Senior

Min 5 yrs required

Full-time

No

Summary:

- Job Title: Investigator Senior
- Job Family: FRD > Investigation
- Type: Full time
- Date Posted: May 02, 2024
- Anticipated End Date: May 09, 2024
- Reference: JR113110
- Salary: Competitive and market-competitive total rewards package
- Experience: Minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background.
- Location: Hybrid model (remote and office)
- Ideal candidate should live within 50 miles of one of Elevance Health's PulsePoint locations

Responsibilities:

- Independently identify, investigate and develop complex cases against perpetrators of healthcare fraud
- Recover corporate and client funds paid on fraudulent claims
- Conduct claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems
- Responsible for independently identifying and developing enterprise-wide specific healthcare investigations and initiatives
- Interface with Senior level management and legal department throughout investigative process
- Assist in training of internal and external entities
- Develop and maintain rapport and cooperation with law enforcement and regulatory agencies
- Represent the company in court proceedings regarding research findings
- Develop and maintain a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts
- Develop and maintain a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts

Requirements:

- BA/BS and minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background
- Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting
- Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job-related designation preferred
- Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred

Who We Are:

- Elevance Health is a Fortune 25 company with a longstanding history in the healthcare industry
- Dedicated to improving lives and communities through making healthcare simpler
- Looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve
- Creating a culture that promotes personal and professional growth for our associates
- Values and behaviors are the root of our culture, driving our shared success

Benefits:

- Market-competitive total rewards package
- Merit increases, paid holidays, Paid Time Off, and 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

Workforce Strategy:

- Hybrid model (remote and office)
- Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week
- Specific requirements and expectations for time onsite will be discussed as part of the hiring process
- Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location

COVID-19 Vaccination Policy:

- The health of our associates and communities is a top priority for Elevance Health
- All new candidates in certain patient/member-facing roles are required to become vaccinated against COVID-19
- Offer will be rescinded if candidate is not vaccinated, unless an acceptable explanation is provided
- Elevance Health will follow all relevant federal, state and local laws

Equal Employment Opportunity:

- Elevance Health is an Equal Employment Opportunity employer
- All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws
- Applicants who require accommodation to participate in the job application process may contact for assistance

Not specified

Medical, Dental, Vision, Short and Long Term Disability, 401(k) +match, Stock Purchase Plan, Life Insurance, Wellness Programs, Financial Education Resources, Paid Holidays, Paid Time Off, Incentive Bonus Programs

Not specified

Claim reviews, Coding, Data Mining, Entity review, Law Enforcement referral, Proprietary data and claim system review, Training, Rapport building, Cooperation, Policy development, Procedure development, Research, Health insurance policies, Claims handling, Provider network contracting

Bachelor's degree in related field

Submit resume to

Qualification and Experience Bachelor's degree in related field, professional certification (CFE, AHFI, CPC, Paralegal, RN, JD), minimum of 5 years experience in healthcare insurance and investigation

Legal