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Fraud Investigation Specialist

2 months ago

Grand Prairie, Texas, United States Elevance Health Full time
Position Title:
Fraud Investigation Specialist

Job Overview:

The Fraud Investigation Specialist plays a crucial role in examining assigned cases, gathering, scrutinizing, and interpreting claim information to identify fraudulent, abusive, or wasteful practices within the healthcare sector.

Key Responsibilities:
  • Utilizing relevant systems and databases to analyze data and review professional and facility claims to uncover fraudulent, abusive, or wasteful healthcare insurance payments.
  • Conducting statistical and financial analyses and generating reports to document findings while maintaining up-to-date electronic case files for management review.
  • Drafting comprehensive case reports and issuing notification letters regarding findings to providers.
  • Evaluating settlement offers for management discussion and review.
  • Exhibiting strong communication skills, both verbal and written, for effective interaction with all stakeholders regarding findings.
Minimum Qualifications:
  • A Bachelor’s degree and a minimum of 2 years of relevant experience, preferably in healthcare insurance departments such as Grievance and Appeals, Contracting, or Claim Operations, law enforcement; or a combination of education and experience that provides an equivalent background.
Preferred Qualifications:
  • Certification in fraud investigation from recognized bodies such as CFE, AHFI, AAPC, or relevant coding certifications.
  • Familiarity with Plan policies and procedures across various benefit program management aspects, with a strong emphasis on negotiation.
  • Experience in health insurance or law enforcement is preferred.
Job Level:
Non-Management Exempt

Work Schedule:
1st Shift (United States of America)

Job Family:
FRD > Investigation

Company Overview:

Elevance Health is dedicated to enhancing lives and communities by simplifying healthcare. As a Fortune 25 organization with a rich history in the healthcare industry, we seek leaders at all levels who are committed to making a positive impact on our members and the communities we serve.

Work Culture:

At Elevance Health, we foster a culture designed to support our strategic goals while promoting personal and professional growth for our associates. Our core values and behaviors are integral to our culture, driving our success for consumers, associates, communities, and the business as a whole.

We provide a competitive range of total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs, alongside comprehensive medical, dental, vision, and disability benefits, a 401(k) plan with matching, stock purchase options, life insurance, wellness initiatives, and financial education resources.