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Senior Fraud Investigation Specialist

2 months ago

Mendota Heights, Minnesota, United States Elevance Health Full time
Elevance Health - Senior Fraud Investigation Specialist
This role is designed to operate in a hybrid work environment, requiring attendance at the office 1-2 times weekly. The preferred candidate should reside within a reasonable distance from one of our Elevance Health PulsePoint locations.

About Carelon Payment Integrity:
Carelon Payment Integrity, a distinguished member of the Elevance Health family, is committed to identifying, mitigating, and preventing unnecessary healthcare expenditures.

Key Responsibilities:
  • Independently uncover, examine, and construct intricate cases against individuals involved in healthcare fraud to reclaim corporate and client funds lost to fraudulent claims.
  • Perform comprehensive claim assessments focusing on accurate coding, data analysis, entity evaluations, law enforcement referrals, and leveraging proprietary data and claims systems for the review of various claims.
  • Identify and initiate organization-wide healthcare investigations and projects that may influence multiple health plans, lines of business, or jurisdictions.
  • Collaborate internally with senior leadership and the legal team throughout the investigative process.
  • Facilitate training sessions for both internal and external stakeholders.
  • Contribute to the formulation of policies and procedures aimed at safeguarding company assets.
  • Represent the organization in legal proceedings concerning investigative findings.
  • Establish and maintain professional relationships with federal, state, and local law enforcement and regulatory bodies to support investigative activities.

Minimum Qualifications:
A Bachelor’s degree and a minimum of 5 years of relevant experience in healthcare insurance, healthcare investigations, or law enforcement; or an equivalent combination of education and experience.

Preferred Skills and Experience:
  • Professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or other relevant designations are highly regarded.
  • In-depth knowledge of plan policies and procedures related to benefit program management, particularly in negotiation.
  • Proficiency in Excel is advantageous.
  • Experience within a Managed Care Organization is a plus.

Compensation and Benefits:
For candidates working in-person or remotely, the salary range for this position is between $77,028 and $126,546. In addition to competitive salaries, Elevance Health provides a comprehensive benefits package, including incentive programs, equity stock purchase options, and 401k contributions (subject to eligibility requirements). The salary offered reflects various legitimate, non-discriminatory factors established by the company. Elevance Health is dedicated to ensuring equitable pay opportunities for equal work, regardless of gender, race, or any other protected category under federal, state, and local pay equity laws. The stated salary range represents the company's assessment of potential compensation for this role at the time of posting and may be adjusted in the future based on geographic location, experience, education, and skill level.