Senior Investigator

Min 5 yrs required

Full-time

No

Summary:

Title: Senior Investigator (Investigator Sr)
Location: Hybrid (Remote and Office)
Salary: Competitive, based on experience and qualifications
Job Type: Full-time
Date Posted: May 02, 2024
Anticipated End Date: May 16, 2024
Reference: JR113107

Location: Indiana, Indianapolis; Maryland, Hanover; Ohio, Columbus; Rhode Island, Smithfield; Florida, Tampa; New Jersey, Iselin; Virginia, Richmond; Illinois, Chicago; Georgia, Atlanta

Company: Carelon Payment Integrity (a member of Elevance Health family of companies, formerly known as Payment Integrity)
Department: Carelon Insights (formerly Payment Integrity)

Company Overview:

Elevance Health is a Fortune 25 health company dedicated to improving lives and communities through simplified healthcare. They are looking for passionate leaders at all levels to make an impact on their members and the communities they serve. Elevance Health offers a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs, as well as medical, dental, vision, and disability benefits.

Job Description:

The Senior Investigator (Investigator Sr) is responsible for independently identifying, investigating, and developing complex cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims. This position will work in a hybrid model (remote and office) and the ideal candidate should live within 50 miles of one of Elevance Health's PulsePoint locations.

Responsibilities:

- Conduct 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
- Independently identify and develop enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business, and/or state
- Interface with senior level management and legal department throughout the investigative process
- Assist in training internal and external entities
- Develop and maintain a high degree of rapport and cooperation with federal, state, and local law enforcement and regulatory agencies
- Assist in the development of policies and procedures to prevent loss of company assets
- May be called upon to represent the company in court proceedings regarding research findings

Requirements:

- degree 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, claims handling, and provider network contracting
- Proficient in Microsoft Excel and its functionality strongly preferred
- 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 Information:

- Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health
- Elevance Health operates in a Hybrid Workforce Strategy, requiring associates to work at an Elevance Health location at least once per week
- The health of associates and communities is a top priority for Elevance Health, and they require all new candidates in certain patient/member-facing roles to become 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. 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 benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, financial education resources

Not specified

Data mining, claim reviews, Microsoft Excel, legal proceedings, research, policy development, negotiation, communication, problem-solving

BA/BS

Submit resume to

Qualification and Experience BA/BS

Legal