Investigator Senior
Elevance Health

Job Info

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Investigator Senior

Supports the Payment Integrity line of business

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles from one of our posted Elevance Health locations.

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

How will you 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 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.
  

Minimum 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.
  

Preferred Qualifications, Skills & Capabilities

• 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.
  
• Bilingual candidate who can speak Spanish is preferred.
  

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $73,360 to $132,048.

Locations: California; Colorado; District of Columbia (Washington, DC), Maryland, New York; Washington State.

In addition to your salary, 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). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

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