Investigator SrSchedule: 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 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.