Investigator II

Elevance Health•Nashville, TN

1d•Hybrid

About The Position

The Investigator II is responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. 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 care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending.

Requirements

Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.
Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
Health insurance, law enforcement experience preferred.

Responsibilities

Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims.
Identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state.
Effectively establish rapport and on-going working relationship with law enforcement.
May interface internally with Senior level management and legal department throughout investigative process.
May assist in training of internal and external entities.
Assists in the development of policy and/or procedures to prevent loss of company assets.