Investigator Sr, Commercial

Elevance Health•Indianapolis, IN

1d•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 operates in a hybrid work environment, requiring associates to be in-office 1-2 days per week for collaboration and connectivity, while also offering flexibility for productivity and work-life balance. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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

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

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.
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.
Interfacing internally with Senior level management and legal department throughout investigative process.
Assisting in training of internal and external entities.
Assisting in the development of policy and/or procedures to prevent loss of company assets.
Representing the Company in court proceedings regarding research findings.
Developing and maintaining a high degree of rapport and cooperation with Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.