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 LEAD INVESTIGATOR is responsible for providing leadership and guidance to the Special Investigations Unit team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Provides comprehensive sound judgment in the application of various investigative methodologies to team members and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating Fraud, Waste and Abuse within the healthcare industry.
How you will make an impact:
- Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day-to-day operations as assigned by management.
- Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers.
- Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review.
- Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel.
- Creates and presents settlement offers for provider issues for review and approval by management and/or legal.
- Communicates orally and in writing with all customers, internal and external, regarding findings.
- Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets.
- Prepares and delivers training to internal and external entities.
- 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.
- Represents the Company in court proceedings regarding research findings.
- Provides guidance to investigators and other SIU staff in the development of criminal and recovery cases.
- Leads SIU projects or initiatives.
- Requires a BA/BS and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Qualifications, and Experiences:
- 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.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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. Applicants who require accommodation to participate in the job application process may contact email@example.com assistance.