Investigator II

Elevance Health • Tampa, FL

1d • Remote

About The Position

The Investigator II identifies, investigates, and develops cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims. The role conducts claim reviews, data mining, entity reviews, and law-enforcement referrals, using proprietary data and claim systems to review facility, professional, and pharmacy claims. It also develops enterprise-wide investigations that may affect multiple company health plans, lines of business, or states. The Investigator establishes and maintains working relationships with law enforcement, may interact with senior management and the legal department during investigations, may help train internal and external entities, and assists with policies and procedures intended to prevent loss of company assets.

The position is described as primarily virtual, with required in-person training sessions. Candidates must live within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law. Elevance Health also describes a broader hybrid workforce strategy, but this role is specified as virtual.

Requirements

• A BA/BS and at least 3 years of related experience, or an equivalent combination of education and experience.

Nice To Haves

• Advanced Excel proficiency, including the ability to run pivot tables and analyze large datasets.
• Familiarity with CPT coding.
• Fraud certification from CFE, AHFI, or AAPC, or coding certificates.
• Knowledge of Plan policies and procedures across benefit program management, with an emphasis on negotiation.
• Investigative experience, such as in health insurance or law enforcement.

Responsibilities

• Identify, investigate, and develop cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims.
• Review claims for appropriate coding, conduct data mining and entity reviews, make law-enforcement referrals, and use proprietary data and claim systems to review facility, professional, and pharmacy claims.
• Identify and develop enterprise-wide healthcare investigations that may affect more than one company health plan, line of business, or state.
• Establish rapport and maintain ongoing working relationships with law enforcement.
• Interface as needed with senior-level management and the legal department throughout the investigative process.
• Assist with training internal and external entities.
• Assist in developing policies and procedures to prevent the loss of company assets.

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 match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

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