Investigator Sr

Elevance Health • Norfolk, VA

3d • Hybrid

About The Position

Position Overview: 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 Medicare 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 commercial 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 Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.

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 commercial 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

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and 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, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees