Investigator II

Elevance Health•Atlanta, GA

6d•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 is primarily virtual, with required in-person training sessions. Candidates must live within reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law. The position involves reviewing claims and data, developing enterprise-wide investigations, and working with law enforcement and internal stakeholders. The investigator may also support training and help develop policies and procedures to prevent the loss of company assets.

Requirements

A bachelor’s degree (BA/BS) and at least 3 years of related experience, or an equivalent combination of education and experience.
Ability to review claims and use data and claim systems in support of healthcare fraud investigations.

Nice To Haves

Advanced Excel proficiency, including running pivot tables and analyzing 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 emphasis on negotiation.
Investigative experience, such as in health insurance or law enforcement.

Responsibilities

Review facility, professional, and pharmacy claims for appropriate coding, using data mining, entity review, law enforcement referrals, proprietary data, and claim systems.
Identify and develop enterprise-wide healthcare investigations that may affect multiple company health plans, lines of business, or states.
Establish and maintain effective working relationships with law enforcement.
Interface with senior management and the legal department during investigations, as needed.
Assist with training internal and external entities.
Assist in developing policies and procedures to prevent loss of company assets.