Responsible for directing all activities of the Fraud Investigations Unit in assigned territory.
Primary duties may include, but are not limited to:
- Supervises and coordinates the investigations of alleged fraud in pharmacy environment.
- Coordinates the analysis of provider utilization patterns and trends and of provider billing and financial data an supervises the case inventory to include monitoring of aging and priority.
- Oversees the integration of various computer systems in the Unit, to include monitoring of aging and priority.
- Coordinates the review of documentation to ensure validity and applicability of data, the preparation of written summaries of the investigations, and the development of cases to be referred to the Office of the Inspector General (OIG).
- Continually communicates with CMS, OIG, and Department of Justice regarding current fraud trends, current case issues, and current analyses and training opportunities.
- Actively participates in ISO Certification renewal, proposals and transitions of additional PSC business and serves as a lead for specified functions.
- Keeps abreast of changes in benefits, policies and regulations and in CMS performance standards and assists management in the interpretation of policies and procedures.
- Works in conjunction with the Quality Management Supervisor to maintain a quality assurance and improvement program that is in accordance with the ISO Quality Management System.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requires a BA/BS in business or nursing and minimum of 5 years in investigations; or any combination of education and experience, which would provide an equivalent background.
*Pharmacy Investigation experience is STRONGLY PREFERRED.
The Government requires that personnel working on Medicare Fraud investigations are U.S. Citizens.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $85,560 to $152,208
Locations: California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY
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.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. 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 for assistance.