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Senior Fraud Investigation Specialist
2 months ago
Position Overview:
This role operates on a hybrid model, combining remote work with occasional office attendance. The ideal candidate should reside within a reasonable distance from one of our Elevance Health PulsePoint locations.
About Carelon Payment Integrity:
As a vital part of the Elevance Health family, Carelon Insights is dedicated to identifying, mitigating, and preventing unnecessary healthcare expenditures.
Key Responsibilities:
- Conduct thorough reviews of claims to ensure proper coding and compliance.
- Engage in data analysis and entity assessments, with potential referrals to law enforcement as necessary.
- Independently spearhead comprehensive healthcare investigations that may affect multiple health plans or business lines.
- Collaborate with senior management and legal teams throughout the investigative process.
- Provide training and support to both internal and external stakeholders.
- Contribute to the formulation of policies and procedures aimed at safeguarding company assets.
- Represent the organization in legal proceedings related to investigative findings.
- Foster strong relationships with federal, state, and local law enforcement and regulatory bodies to enhance investigative efforts.
Minimum Qualifications:
- A Bachelor’s degree coupled with a minimum of five years of relevant experience in healthcare insurance, investigations, or law enforcement, or an equivalent combination of education and experience.
Preferred Qualifications:
- Professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or similar designations are advantageous.
- Familiarity with healthcare plan policies and procedures, particularly in negotiation, is preferred.
- Proficiency in Excel is a plus.
- Experience within a Managed Care Organization is also beneficial.
Compensation:
The salary range for this position is competitive and commensurate with experience and qualifications. Elevance Health provides a comprehensive benefits package, including incentive programs, equity stock purchase options, and 401k contributions, all subject to eligibility criteria.
Commitment to Equity:
Elevance Health is dedicated to ensuring equitable pay opportunities for all employees, regardless of gender, race, or other protected categories.
