Investigator Senior - Pharmacy

Elevance Health • St. Louis, MO

89d

About The Position

The Investigator Senior - Pharmacy position is responsible for the independent identification, investigation and development of complex Healthcare 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-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.

Requirements

• Requires a BA/BS and minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background.
• Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.

Nice To Haves

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation 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.
• Independently identify and develop enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state.
• 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.
• Represent the Company in court proceedings regarding research findings.
• Develop and maintain a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees