Manager I Investigations

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.

Carelon Health is a proud member of the Elevance Health family of brands, offering clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.

The  MANAGER I INVESTIGATIONS  is responsible for directing all activities of the Fraud Investigations Unit in assigned territory.

How you will make an impact:

• 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.

Minimum Requirements:

• 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.

Preferred Skills, Capabilities and Experiences:

• Investigation knowledge and experience strongly preferred.
• Prior management experience 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 and Influenza. 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 elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.