Investigator II

Location Hybrid 1: 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 remote work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

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. 

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 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.

• Pharmacy technician license and/or experience preferred.

• Formulary, clinical rules, pharmacy claims analysis, and/or prior authorization experience for a pharmacy benefit manager or health plan strongly preferred.

• Proficiency with Microsoft Office products, most notably expertise in Excel for reporting, Word, PowerPoint, Teams, and Outlook strongly preferred.

• One year or more Excel experience working with large data files and other general reporting tools preferred.

• Experience with data Mining and data analysis preferred.

• Ability to communicate information clearly and concisely, both orally and in writing, in a professional and legal environment strongly preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $72,912 to $124,992.

Locations:  California; Colorado; Nevada

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.