Investigator Senior supports the Payment Integrity line of business. This role enables associates to work virtually full-time, except for required in-person training sessions, providing flexibility and autonomy. The Investigator Senior is responsible for independent identification, investigation, and development of complex cases against healthcare fraud perpetrators to recover corporate and client funds paid on fraudulent claims. Requires health insurance experience with understanding of policies, claims handling, and provider network contracting. Responsibilities include claim reviews for coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for facility, professional, and pharmacy claims. Develops enterprise-wide healthcare investigations impacting multiple health plans, lines of business, or states. Interfaces with senior management and legal departments, assists in training, develops policies to prevent asset loss, may represent the company in court, and maintains cooperation with law enforcement and regulatory agencies. Minimum requirements include a BA/BS and 5 years related experience in healthcare insurance, investigation, or law enforcement. Preferred certifications include CFE, AHFI, CPC, Paralegal, RN, JD, or related designations. Knowledge of plan policies and negotiation preferred. Salary range for in-person or virtual candidates in specified states is $82,320 to $141,120, with additional benefits including incentive programs, equity stock purchase, and 401k contributions. Elevance Health is committed to equal pay and equal employment opportunity.
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