Investigator Sr, Commercial

Elevance Health•Atlanta, GA

6d•Hybrid

About The Position

The Investigator Sr, Commercial is responsible for the independent identification, investigation, and development of complex 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 accommodation is granted as required by law.

Requirements

Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.
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.

Nice To Haves

Advanced Excel proficiency; ability to run pivot tables and analyze large datasets.
10 years investigative experience.
Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job-related designation.
Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation.

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 independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state.
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.
May be called upon to represent the Company in court proceedings regarding research findings.
Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.