Investigator Senior

Min 5 yrs required

Full-time

No

Summary:

Elevance Health, a Fortune 25 healthcare company, is seeking a Senior Investigator to join their team. This full-time position will work on a hybrid model, with both remote and office work. 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, and entity review
- Utilize proprietary data and claim systems to review facility, professional, and pharmacy claims
- Independently identify and develop complex healthcare investigations
- 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
- Represent the company in court proceedings regarding research findings
- Develop policies and procedures to prevent loss of company assets

Requirements:

- Bachelor's degree and minimum of 5 years experience in healthcare insurance and investigation, or equivalent combination of education and experience
- Understanding of health insurance policies, claims handling, and provider network contracting
- Professional certification in CFE, AHFI, CPC, Paralegal, RN, JD, or related field preferred
- Knowledge of plan policies and procedures in benefit programs management, with emphasis in negotiation

Culture and Benefits:

Elevance Health offers a competitive total rewards package, including merit increases, paid holidays, PTO, incentive bonus programs, and various benefits such as medical, dental, vision, and disability. They also prioritize personal and professional growth for their associates and have a strong company culture based on values and behaviors.

Elevance Health operates on a Hybrid Workforce Strategy, with some virtual and in-person work required. Candidates must reside within 50 miles or 1-hour commute of an Elevance Health location. The company also values the health and safety of their associates and requires vaccination against COVID-19 for certain patient/member-facing roles.

Equal Opportunity Employer:

Elevance Health is an equal employment opportunity employer and does not discriminate based on age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other protected status or condition. Accommodations for the job application process are available for those who require it.

Not specified

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Claim review, coding, data mining, entity review, law enforcement referral, use of proprietary data and claim systems, training, policy development, court representation, rapport building, negotiation

Not specified

Interested candidates should submit their resume to

Qualification and Experience BA/BS

Legal