Manager I Investigations

Elevance Health • Costa Mesa, CA

1d • Hybrid

About The Position

Location: Atlanta GA, Richmond VA, Costa Mesa CA, Indianapolis IN Hours: Standard Working hours Travel: This role requires associates to be in-office 3 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. Position Overview: Responsible for directing all activities of the Fraud Investigations Unit responsible for overseeing assigned Medicaid markets. How You Will Make an Impact: Supervises and coordinates the investigations of alleged Medicaid fraud Coordinates the analysis of provider utilization patterns and trends and of provider billing and financial data and supervises the case inventory to include monitoring of aging and priority Oversees the integration of various computer systems in the Unit, to include monitoring of aging and priority Coordinates the review of documentation to ensure validity and applicability of data, the preparation of written summaries of the investigations, and the development of cases to be referred to the Office of the Inspector General (OIG) Continually communicates with Medicaid state agencies CMS, OIG, and Department of Justice regarding current fraud trends, current case issues, and current analyses and training opportunities Keeps abreast of changes in Medicaid benefits, policies and regulations and in CMS performance standards and assists management in the interpretation of Medicaid policies and procedures Hires, trains, coaches, counsels, and evaluates performance of direct reports

Requirements

• Requires a BA/BS in business or nursing and minimum of 5 years in investigations; or any combination of education and experience, which would provide an equivalent background.
• The Government requires that personnel working on Medicaid Fraud investigations are U.S. Citizens.

Nice To Haves

• Previous management experience is a must
• CFE, AHFI, CPC Certifications preferred
• Experience with Virginia and Arkansas Medicaid preferred

Responsibilities

• Supervises and coordinates the investigations of alleged Medicaid fraud
• Coordinates the analysis of provider utilization patterns and trends and of provider billing and financial data and supervises the case inventory to include monitoring of aging and priority
• Oversees the integration of various computer systems in the Unit, to include monitoring of aging and priority
• Coordinates the review of documentation to ensure validity and applicability of data, the preparation of written summaries of the investigations, and the development of cases to be referred to the Office of the Inspector General (OIG)
• Continually communicates with Medicaid state agencies CMS, OIG, and Department of Justice regarding current fraud trends, current case issues, and current analyses and training opportunities
• Keeps abreast of changes in Medicaid benefits, policies and regulations and in CMS performance standards and assists management in the interpretation of Medicaid policies and procedures
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

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, 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: Manager
• Number of Employees: 5,001-10,000 employees