Investigator I
Elevance Health

Job Info

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Investigator I

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of our St. Louis, Missouri or Winston-Salem, NC and Durham, NC PulsePoint location.

The INVESTIGATOR I is responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices

How you will make an impact:

• Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.
  
• Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.
  
• Preparation of final case reports and notification of findings letters to providers.
  
• Receive offers of settlement for review and discussion with management.
  
• Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.
  

Minimum Requirements:

• Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; 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.
  

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