Investigator I

Elevance Health • Tampa, FL

2d • 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 notification letters to providers; receives settlement offers for review and discussion with management; and communicates findings to internal and external customers.

Requirements

• Bachelor’s degree (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 may qualify.
• Strong oral and written communication skills for contacting internal and external customers.

Nice To Haves

• Investigative experience, such as in health insurance or law enforcement.
• 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 identify fraudulent, abusive, or wasteful activities or practices.
• Use system tools and databases to analyze data and review professional and facility claims for potentially fraudulent, abusive, or wasteful healthcare insurance payments.
• Prepare statistical and financial analyses and reports documenting findings.
• Maintain current electronic case files for management review.
• Prepare final case reports and letters notifying providers of findings.
• Receive settlement offers for review and discussion with management.
• Communicate findings to internal and external customers through oral and written communication.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs, unless covered by a collective bargaining agreement
• Medical benefits
• Dental benefits
• Vision benefits
• Short- and long-term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level