Investigator Senior

Full-time 28 views
Company Anthem, Inc. Location Denison, TX, United States

In-House

Legal Staff

Min 5 yrs required

Full-time

Jun 13, 2022

Sep 26, 2022

Jun 22, 2021

Profile

Investigator Senior
The Candidate will be responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims. Responsible for independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state. May interface internally with Senior level management and legal department throughout investigative process. May assist in training of internal and external entities. Assists in the development of policy and/or procedures to prevent loss of company assets. May be called upon to represent the Company in court proceedings regarding research findings. Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts. Requires BA/BS degree 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. 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.

Additional info

Req #: PS52770

Company info

Hiring Coordinator
Anthem, Inc.
2415 S Austin Ave
Denison, TX 75020

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