Clinical Fraud Investigator II - Registered Nurse and CPC - Carelon Payment Integrity SIU
About The Position
Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU Location: 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. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risks associated with fraud and abuse.
Requirements
- Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and minimum of 4 years related experience, including minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.
Nice To Haves
- Fraud and Abuse experienced Nurse with a CPC are highly desired.
Responsibilities
- 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.
Benefits
- In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Insurance Carriers and Related Activities
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
