CareBridge-posted 3 months ago
$65,968 - $124,992/Yr
Full-time • Mid Level
Metairie, LA
251-500 employees
Ambulatory Health Care Services

The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risks associated with fraud and abuse. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, determined to recover, eliminate and prevent unnecessary medical-expense spending.

  • Performs comprehensive analysis and clinical evaluation of the collected data.
  • Performs in-depth investigations on identified providers as warranted.
  • Examines claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.
  • Review and conducts analysis of claims and medical records prior to payment.
  • Researches new healthcare-related questions as necessary to aid in investigations.
  • Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.
  • Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
  • Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA).
  • Minimum of 4 years related experience, including minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area.
  • Any combination of education and experience, which would provide an equivalent background.
  • Fraud and Abuse experienced Nurse with a CPC are highly desired.
  • Comprehensive benefits package.
  • Incentive and recognition programs.
  • Equity stock purchase.
  • 401k contribution.
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