Investigator II

Investigator II

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.

Title: Investigator II

Locations: Indianapolis, IN, Columbus, OH, Nashville, TN

Hybrid: 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 if candidates reside within a commuting distance from an office.

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.

Primary duties may include, but are not limited to:

• 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 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 on-going working relationship 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 policy 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, Capabilities 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, law enforcement experience preferred.

Job Level: Non-Management Exempt

Workshift:

Job Family: FRD > Investigation

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

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, 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.