Job DescriptionInvestigator ISchedule: 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 I position is responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices.This is how you will make an impact:
Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.
Review of medical records to include progress notes, treatment plans, and other documentation required to support billed services.
Review and interpretation of regulations, provider handbooks, and other regulatory documentation.
Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.
Preparation of final case reports and notification of findings letters to providers.
Receive offers of settlement for review and discussion with management.
Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.
Minimum Requirements:
BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Special Investigations, Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities, and Experiences:
Proficient in Microsoft Excel