Investigator I

Elevance Health•Tampa, FL

5d•$61,200 - $76,500•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. Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health.

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.

Nice To Haves

At least 2 years of investigative/audit experience in healthcare FWA/SIU, payment integrity, compliance investigations, or a closely related environment
Strong claims analytics capability: experience performing comparative/outlier analysis and translating trends into a clear allegation narrative with defensible supporting artifacts (e.g., data pulls, comparisons, trend summaries).
Medical record review and synthesis experience, including summarizing record findings into investigative conclusions and formal written reports.
Demonstrated case management discipline: building/maintaining complete digital case files with communications, evidence, investigation steps, and approval trails.
Experience drafting investigation plans and findings reports for client or stakeholder review/approval, including clear dispositioning (founded/unfounded) and recommended next steps.
Working knowledge of common FWA indicators relevant to claims review (e.g., overutilization, upcoding, sudden spikes, outlier behavior compared to peers).
Cross-functional collaboration experience, including partnering with clinical auditors and recovery/data-mining teams and making clean handoffs for remediation and recovery.
Excellent written communication skills, especially for defensible documentation (allegations, evidence summaries, provider notification content, and remediation recommendations).

Responsibilities

Review and triage investigative leads generated by claims-based anomaly detection, prioritizing work based on probability of FWA and benefit risk to the client.
Conduct comparative claims/data analysis to determine whether aberrant billing patterns warrant an allegation and investigation (e.g., overutilization, usage spikes, upcoding; outlier comparison to similar/same providers).
Draft investigation recommendations for client approval, including: allegation statement; evidence/artifacts from analysis; and an investigation plan covering targets (codes/groupings/providers), steps (records requests/surveys/interviews), scope (sample size/date ranges), affected claims universe, and anticipated financial impact.
Create and maintain digital case records that clearly define investigation scope and contain all case artifacts/collateral, including client requests/approvals and the investigation plan used as the investigation roadmap.
Execute investigation plans by requesting and reviewing medical records, performing additional data/evidence collection as warranted, and storing investigation steps and communications in the digital case record.
Ensure compliance with client-approval requirements, including obtaining written client approval before any provider/member-facing requests, surveys, or interviews and before changes in flagged provider status.
Prepare comprehensive findings reports that document founded/unfounded dispositions, cite defensible evidence from records and data collected, and recommend next steps (remediation vs. referral to law enforcement), including a request for client approval to proceed.
Support approved remediation activities, including issuing provider notification of findings with required behavior changes and coordinating remediation options (education + post-pay tracking; prepayment monitoring; overpayment recovery referral
Coordinate with clinical auditors during prepayment monitoring (PPR) by supporting targeted audit workflows and understanding routing outcomes (approve/pay, partial denial, full denial) and program completion/limitation criteria.