Senior Investigator

Min 5 yrs required

Full-time

No

Job Title: Senior Investigator (Investigator Sr)
Salary: Competitive salary, based on experience and qualifications
Experience: Minimum 5 years of experience in healthcare insurance and healthcare insurance investigation, law enforcement or related field

Job Description:

The Senior Investigator (Investigator Sr) position is a full-time role within the Carelon Payment Integrity division of Elevance Health. The ideal candidate will have a strong background in healthcare insurance and investigation, with a minimum of 5 years of experience in the field. This position will work a hybrid model, with both remote and office work, and the candidate should live within 50 miles of one of our Elevance Health 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 complex 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 of internal and external entities.
- Develop and maintain a high degree of rapport and cooperation with law enforcement and regulatory agencies to assist in investigative efforts.
- Represent the company in court proceedings regarding research findings.
- Assist in the development of policies and procedures to prevent loss of company assets.

Requirements:

- Bachelor's degree () or equivalent experience
- Minimum of 5 years of related experience in healthcare insurance and healthcare insurance investigation, law enforcement, or a related field
- Knowledge of health insurance policies, claims handling, and provider network contracting
- Understanding of plan policies and procedures in all facets of benefit programs management, with a focus on negotiation
- Proficiency in Microsoft Excel and its functionality
- Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designation preferred

Benefits:

- Competitive salary, based on experience and qualifications
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical, dental, and vision insurance
- Short and long term disability benefits
- 401(k) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources

Working at Elevance Health:

Elevance Health is a Fortune 25 company with a longstanding history in the healthcare industry. We are dedicated to improving lives and communities and making healthcare simpler. We are looking for passionate leaders at all levels of the organization who want to make a positive impact on our members and the communities we serve.

At Elevance Health, we are committed to creating a culture that fosters personal and professional growth for our associates. Our values and behaviors are the foundation of our culture, driving our shared success and achieving our strategic goals.

We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. We also provide medical, dental, and vision insurance, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources, among others.

Elevance Health operates in a Hybrid Workforce Strategy, with associates required to work at an Elevance Health location at least once per week. Candidates must live within 50 miles or a 1-hour commute of a relevant Elevance Health location.

The health and safety of our associates and communities is a top priority at Elevance Health. We require all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health follows all relevant federal, state, and local laws.

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. If you require accommodation to participate in the job application process, please contact for assistance.

Not specified

Paid holidays, Paid Time Off, incentive bonus programs, medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, financial education resources

Not specified

Claim review, data mining, entity review, Microsoft Excel, negotiation, policy development, legal representation

BA/BS

Submit resume through Elevance Health or through a signed agency agreement.

Qualification and Experience BA/BS

Legal