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 Medicare fraud. 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 Medicare benefits, policies and regulations and in CMS performance standards and assists management in the interpretation of Medicare 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. The Government requires that personnel working on Medicare Fraud investigations are U.S. Citizens.
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. A Fortune 20 company with a longstanding history in the healthcare industry, 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 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 – 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 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. 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 firstname.lastname@example.org for assistance.