Investigator I

Elevance Health•Atlanta, GA

1d•Remote

About The Position

The Investigator I investigates assigned cases by collecting, researching, and analyzing claim data to detect fraudulent, abusive, or wasteful activities and practices. The role uses system tools and databases to analyze data and review professional and facility claims for potentially improper healthcare insurance payments to providers and subscribers. The investigator prepares statistical and financial analyses, reports, electronic case files, final case reports, and findings letters to providers; reviews settlement offers with management; and communicates findings to internal and external customers.

Requirements

A BA/BS and at least 2 years of related experience, preferably in healthcare insurance departments such as Grievance and Appeals, Contracting, or Claim Operations, or in law enforcement; an equivalent combination of education and experience is also acceptable.
Oral and written communication skills.

Nice To Haves

Investigative experience, such as in health insurance or law enforcement.
Strong Excel proficiency, including the ability to run pivot tables and analyze large datasets.
Familiarity with CPT coding.

Responsibilities

Investigate assigned cases by collecting, researching, and analyzing claim data to detect fraudulent, abusive, or wasteful activities and practices.
Use system tools and databases to analyze data and review professional and facility claims for potentially improper healthcare insurance payments to providers and subscribers.
Prepare statistical and financial analyses and reports documenting findings.
Maintain up-to-date electronic case files for management review.
Prepare final case reports and notification-of-findings letters to providers.
Receive settlement offers for review and discussion with management.
Communicate with internal and external customers about findings.