Senior Investigator

2 weeks ago


Virginia, United States Elevance Health Full time

Senior Investigator (Investigator Sr) 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 Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate, and prevent unnecessary medical-expense spending. The

Senior Investigator

is responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. How you will make an impact: Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims. Responsible for independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state. May interface internally with Senior level management and legal department throughout investigative process. May assist in training of internal and external entities. Assists in the development of policy and/or procedures to prevent loss of company assets. May be called upon to represent the Company in court proceedings regarding research findings. Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts. Minimum Requirements: Requires a BA/BS and minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities, and Experiences: Proficient in the utilization of Microsoft Excel and its functionality strongly preferred. Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred. Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

#J-18808-Ljbffr


  • Senior Auditor

    24 hours ago


    Virginia, United States Catholic Charities Community Services Full time

    You are viewing a preview of this job. Log in or register to view more details about this job. The Virginia Department of Transportation is excited to announce an opportunity to serve as a Senior Auditor in the Assurance and Compliance Office (ACO). This position is based in the VDOT Central Office located in downtown Richmond, Virginia. We are looking for...

  • Senior Writer

    3 weeks ago


    Dahlgren, Virginia, United States Library Systems & Services Full time

    LAC Federal is seeking a Senior Writer/Editor to support content creation, editing, and updating for a component of the United States Department of Defense technical information program. The Senior Writer/Editor will play a pivotal role in writing, editing, and overseeing the production of a variety of documents, articles, and content in journalistic (AP)...


  • West Virginia, United States Johnson & Johnson Full time

    Johnson and Johnson Innovative Medicine, is recruiting for a Senior Medical Science Liaison, Schizophrenia in the territory comprising MI, OH, IN, KY, WV. At Johnson and Johnson Innovative Medicine, we are working to create a world without disease. Transforming lives by finding new and better ways to prevent, intercept, treat and cure disease inspires us....


  • Virginia, United States Yodlee Full time

    Envestnet is seeking a passionate and talented Senior Information Security Specialist to join our MoneyGuide team. This position is expected to report to our Powhatan, VA office.Envestnet is transforming the way financial advice and wellness are delivered. Our mission is to empower advisors and financial service providers with innovative technology,...


  • Richmond, Virginia, United States Timmons Group Full time

    Job Description Timmons Group is seeking a Senior Construction Materials Testing Technician for our Geotechnical and Construction Services Group located in our Richmond, VA office location. Under the direction of the Construction Materials Testing (CMT) Manager, Senior Construction Materials Testing Technician applies learned skills and technical...


  • Virginia Beach, United States Globalstar Full time

    The Senior Fire Protection Engineer position is a technical role within the firm focused on project execution for a variety of multi- and single-discipline facility design projects. The Senior Fire Protection Engineer will be responsible for performing multiple aspects of fire protection engineering services on multi-discipline building design projects of...


  • Virginia Beach, United States Capstone ISG Inc Full time

    Job DescriptionJob DescriptionDescription: Capstone ISG Inc. was founded in 2003 and is dedicated to providing accurate and high-quality claims services to insurance companies, government, and the Lloyds market. With a goal to become the nation's top adjusting company, Capstone is expanding nationwide and looking for talented Field Adjusters to join...


  • Quantico, Virginia, United States Resource Management Concepts, Inc. Full time

    Resource Management Concepts, Inc. (RMC) provides high-quality, professional services to government and commercial sectors. Our mission is to deliver exceptional management and technology solutions supporting the protection and preservation of the people and environment of the United States of America. RMC is hiring a Senior Tool Management Operator to...

  • Senior Planner SME

    4 days ago


    Hampton, Virginia, United States Credence Management Solutions, LLC Full time

    Overview: Credence Management Solutions, LLC (Credence) is seeking a Senior Planner SME to support our Air Combat Command (ACC) Intelligence Directorate (A2) program out of Langley AFB, VA. This position will be supporting the A28- Capabilities based planning. The Senior Planner SME shall assist ACC and the USAF in conducting studies, analyses, and...


  • King George, Virginia, United States VTG Full time

    Overview: VTG is seeking a Senior Systems Engineer to support the Naval Surface Warfare Center Dahlgren Division (NSWCDD) Integrated Combat Systems Department in Dahlgren, VA. This is a mostly onsite role with limited telework capability.  Responsibilities: The individual hired into this position will provide senior systems engineering support to NSWCDD...

  • Senior HR Manager

    4 weeks ago


    Herndon, Virginia, United States Two95 International Inc. Full time

    Hi, Job Title: Senior HR Manager Location: Herndon, VA Position: Full-Time Salary: ($Best Possible) Description: The Senior Manager of HR is part of the Executive Leadership Team and will assist in all HR functions working under the direction of the President and CEO. The Senior Manager HR is responsible for full-cycle human resources...


  • Virginia Beach, United States City of Virginia Beach Full time

    The City of Virginia Beach Department of Human Services is seeking to hire a Senior Pretrial Probation Officer who has experience working with individuals with Mental Health and Substance Abuse disorders with Local Probation and Pretrial Services and experience training and coaching peers and/or co-workers for the Community Corrections and Pretrial Services...

  • Network Engineer

    4 weeks ago


    Keyser, West Virginia, United States The Squires Group Full time

    Overview : Our client, one of the nation’s largest technology and consulting firms, is looking for a Senior Network Engineer.  The Senior Network Engineer will provide technical support to maintain a large number of security and network devices.  You will be responsible for providing maintenance of these devices with the latest patch levels, daily...


  • Virginia, United States St. Louis County Full time

    Incumbents for the position(s) will perform professional planning, administrative, and project management work involving responsibility of short-and long-range program planning and implementation in assigned functional area of the County. Planner (A) - Land Use: The incumbent of this position will perform a broad range and an advanced set of professional...

  • Senior Director

    4 weeks ago


    Reston, Virginia, United States Fannie Mae Full time

    Job Description In this compelling leadership position, you will plan and direct the work of a team who organize cloud-related incidents while proposing and implementing solutions to quickly restore service in order to eliminate or minimize business impact to external and internal customers. In this role, you will coordinate operational activities of the...


  • Marion, Virginia, United States General Dynamics Mission Systems, Inc Full time

    Basic Qualifications : Requires a Bachelor’s degree in Engineering, or a related Science or Mathematics field. Also requires 2+ years of job-related experience or a Master's degree.   CLEARANCE REQUIREMENTS: Department of Defense Secret security clearance is required within a reasonable amount of time after hire. Applicants selected will be subject to...


  • Virginia Beach, United States REI Engineers Full time

    Job DescriptionJob DescriptionSalary: DOEWorking under the general direction of more senior project managers and within defined guidelines, apply engineering principles and concepts learned from previous experience and and/or formal education. Plan and perform project management; assist with engineering duties for design, construction administration,...


  • Manassas, Virginia, United States ECPI University Full time

    Overview: Director of Employee Relations This position can work at ECPI University’s Manassas, VA campus location.   Transform your Career at ECPI University Since 1966, the dedicated employees at ECPI University have helped students achieve their goals via practical training and career-focused education with over 50 Associates, Bachelor’s and...


  • Virginia, United States IPsoft Full time

    Information Security Engineer page is loaded Information Security Engineer Apply locations Bangalore Office - BLR2 time type Full time posted on Posted 30+ Days Ago job requisition id R10001260 Collaboration between humans and machines is the ultimate opportunity for today’s enterprises, and no company is more prepared to lead this march toward a...


  • Virginia Beach, United States Gordie Howe Full time

    RESPONSIBILITIESLead project meetings to collect and disseminate information pertaining to the project Responsible for technical specifications/drawings review and issue resolution Coordinate the collection and dissemination of technical information between/within the company and the owner Responsible to develop work plans and procedures that enables...