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.
Carelon Payment Integrity is a proud member of the Elevance Health family of companies. Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate, and prevent unnecessary medical expense spending.
The Investigator II is responsible for the identification, investigation, and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent 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 claims systems for review of facility, professional, and pharmacy claims.
- Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business, and/or state.
- Effectively establish rapport and ongoing working relationships with law enforcement.
- May interface internally with Senior level management and the legal department throughout the investigative process.
- May assist in the training of internal and external entities.
- Assists in the development of policies and/or procedures to prevent loss of company assets.
Minimum Requirements:
- Requires a BA/BS and minimum of 3 years related experience, or any combination of education and experience, which would provide an equivalent background.
Preferred Qualifications, Skills, and Experiences:
- Fraud certification from CFE, AHFI, AAPC, or coding certificates preferred.
- Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
- Health insurance and/ or law enforcement experience preferred.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
