Clinical Fraud Investigator

7 days ago


Grand Prairie, Texas, United States Elevance Health Full time
Job Overview

Elevance Health is a leading health company dedicated to improving lives and communities. We are seeking an experienced Clinical Fraud Investigator to join our team in a critical role.

About the Role

This position involves identifying potential risks associated with fraud and abuse in the healthcare industry. The successful candidate will be responsible for conducting data mining activities, performing comprehensive analysis and clinical evaluation of collected data, and examining claims for compliance with relevant billing and processing guidelines.

The ideal candidate will have a strong background in nursing and/or certified professional coding, with a minimum of 4 years of experience in a related field. Experience in fraud and abuse investigations is highly desired.

Key Responsibilities
  • Conducts data mining activities using available tools and internal data warehouse.
  • Performs comprehensive analysis and clinical evaluation of collected data.
  • Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
  • Reviews and conducts analysis of claims and medical records prior to payment.
  • Researches new healthcare-related questions as necessary to aid in investigations.
Requirements

We require an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and a minimum of 4 years related experience, including a minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area.

Benefits

Elevance Health offers a competitive salary range of $70,140 to $120,240, depending on location and experience. We also offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. In addition, we offer a Hybrid Workforce Strategy, which allows associates to work from home and in the office. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

Work Environment

This position will work a hybrid model (remote and office), with the ideal candidate living within 50 miles of one of our Elevance Health locations. The work shift is 1st Shift (United States of America). Job Family: FRD > Investigation.


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