Investigator II - Carelon Payment Integrity
Elevance Health

Investigator II - Carelon Payment Integrity

Location: The ideal candidate will live within 50 miles of one of our OH, TN, IN, or NJ offices and will work on a hybrid work model (1-2 days per week in the office).

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.

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 legal department throughout investigative process.
• May assist in 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 Skills, Qualifications, 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 on negotiation preferred.
• Health insurance and law enforcement experience preferred.
• Microsoft Excel proficiency strongly preferred.
• Medicaid claims knowledge desired.

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