Investigator Senior

Min 5 yrs required

Full-time

No

Summary:

The Investigator Senior position at Elevance Health is responsible for independently identifying, investigating and developing complex cases of healthcare fraud in order to recover funds paid on fraudulent claims. This is a full-time position with a hybrid work model, meaning the ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations. The position requires a minimum of 5 years of experience in healthcare insurance and investigation, or a combination of education and experience.

Responsibilities:

- Conduct claim reviews for appropriate coding, data mining, entity review, and law enforcement referral in order to identify cases of healthcare fraud.
- Independently develop enterprise-wide healthcare investigations and initiatives that may impact multiple company health plans, lines of business and/or states.
- Interface with senior level management and legal department throughout investigative process.
- Assist in training internal and external entities.
- Develop and maintain relationships with law enforcement and regulatory agencies to aid in investigative efforts.
- May represent the company in court proceedings regarding research findings.
- Assist in developing policies and procedures to prevent loss of company assets.
- Requires a strong understanding of health insurance policies, claims handling, and provider network contracting.

Minimum Requirements:

- BA/BS degree and a minimum of 5 years of related experience in healthcare insurance and investigation, or a combination of education and experience.
- Professional certification preferred (CFE, AHFI, CPC, Paralegal, RN, JD).
- Knowledge of plan policies and procedures in benefit programs management, with emphasis on negotiation.

Who We Are:

Elevance Health is a Fortune 25 health company dedicated to improving lives and communities through simplified healthcare. We value personal and professional growth and offer a range of competitive benefits including merit increases, paid holidays, paid time off, incentive bonus programs, medical, dental, vision, and disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs, and financial education resources.

How We Work:

At Elevance Health, our culture is designed to advance our strategy and promote personal and professional growth for our associates. Our values and behaviors drive our shared success and guide us in achieving our goals for our consumers, associates, communities, and business. We operate in a hybrid workforce strategy and require all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive 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 status or condition protected by applicable federal, state, or local laws. We offer accommodations for candidates who require assistance in the job application process.

SEO-friendly job title: Investigator Senior at Elevance Health

H1: Investigator Senior at Elevance Health: Identify and Investigate Healthcare Fraud

H2: Responsibilities and Requirements for Investigator Senior Position at Elevance Health

Not specified

Medical, Dental, Vision, Short and Long Term Disability, 401(k) + match, stock purchase plan, life insurance, wellness programs, financial education resources

Not specified

Fraud Detection, Data Mining, Claim Review, Policy Development, Communication, Negotiation, Research, Case Development, Report Writing, Training

Bachelor's degree in a related field

Submit resume to

Qualification and Experience Bachelor's degree in a related field, 5 years of experience in healthcare insurance investigation or law enforcement

Legal