Investigator I

2 weeks ago


Wilmington, Delaware, United States Elevance Health Full time

Job Description

Investigator I

Schedule: 1-2 days per week in the office (Hybrid 1)

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.

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

This is 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.
  • Review of medical records to include progress notes, treatment plans, and other documentation required to support billed services.
  • Review and interpretation of regulations, provider handbooks, and other regulatory documentation.
  • 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:

  • BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Special Investigations, 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:

  • Proficient in Microsoft Excel


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