Job Description

Investigator Sr Schedule: 1-2 days per week in the office (Hybrid 1) Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations. The Investigator Sr. position 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. Candidate will need a strong Medicare/Medicaid background with a focus on Pharmacy. 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 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. Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. 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 Skills, Capabilities and Experiences: Pharmacy investigation experience is highly preferred. Professional certification of Pharm Tech, Pharmacist, 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. Claims & NDC Code experience. Data mining experience. Drug related investigation experience highly preferred. Strong analytical & problem-solving skills. Salary Range: For candidates working in person or remotely in the below location(s), the salary range for this specific position is $78,400 to $141,120. Locations: California; Colorado; Nevada; 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). Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. #J-18808-Ljbffr Elevance Health

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