Investigator II
About The Position
Investigator II Locations: Indianapolis, IN, Nashville, TN, Columbus, OH Hybrid: This role requires associates to be in-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 if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, 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. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. 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. How you will make an impact: 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. Responsible for 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.
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.
- Responsible for 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.
Benefits
- Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs (unless covered by a collective bargaining agreement)
- medical, dental, vision, short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs and financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
