Investigator II

Elevance Health•Durham, NC

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. This role requires associates to be in the office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Requirements

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.
Interface internally with Senior level management and legal department throughout investigative process.
Assist in training of internal and external entities.
Assist in the development of policy and/or procedures to prevent loss of company assets.