Investigator I

Elevance Health•San Juan, PR

2d•Hybrid

About The Position

The Investigator I will be responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. 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. MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.

Requirements

Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.
Candidates are required to reside in Puerto Rico.
Requires associates to be in-office 1 - 2 days per week.

Nice To Haves

Clinical background preferred.
Fully Bilingual (English and Spanish) preferred.
MS office excel skills preferred.

Responsibilities

Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.
Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.
Preparation of final case reports and notification of findings letters to providers.
Receive offers of settlement for review and discussion with management.
Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.