Clinical Fraud Investigator II

Elevance Health•Cincinnati, OH

1d•Hybrid

About The Position

The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk 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 if candidates reside within a commuting distance from an office. 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. This position is not eligible for current or future VISA sponsorship.

Requirements

Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA)
Minimum of 4 years related experience
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.

Nice To Haves

Advanced Excel skills, including Pivot Tables

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 retrospective 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.