Senior Fraud Investigation Specialist
2 weeks ago
Location requirements include 'city, state' or a zip code for radius searches (e.g., Denver, CO or City and state must be separated by a comma followed by a space (e.g., Houston, TX).
Location:
This role operates in a hybrid model (remote and office). The ideal candidate should reside within 50 miles of one of our designated Elevance Health locations.
Carelon Payment Integrity, a proud member of the Elevance Health family, is committed to recovering, eliminating, and preventing unnecessary medical expense spending.
The Senior Fraud Investigation Specialist is tasked with the independent identification, examination, and development of intricate cases against individuals committing healthcare fraud to recover corporate and client funds lost to fraudulent claims.
Key Responsibilities:
Conduct thorough claim reviews for accurate coding, data analysis, entity assessments, law enforcement referrals, and utilize proprietary data and claim systems for the evaluation of facility, professional, and pharmacy claims.
Independently identify and develop enterprise-wide healthcare investigations and initiatives that may affect multiple company health plans, lines of business, and/or states.
Collaborate internally with senior management and legal teams throughout the investigative process.Assist in training both internal and external stakeholders.
Contribute to the formulation of policies and procedures aimed at safeguarding company assets.
May represent the organization in court proceedings regarding investigative findings.
Establish and maintain strong relationships with Federal, State, and local law enforcement and regulatory agencies to support investigative efforts.
Qualifications include a BA/BS degree and a minimum of 5 years of relevant experience in healthcare insurance, healthcare investigations, or law enforcement; or a combination of education and experience that provides an equivalent background.
Experience in health insurance is essential, with a solid understanding of health insurance policies, claims handling, and provider network contracting.Preferred Qualifications:
Professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or other relevant designations are preferred.
Knowledge of plan policies and procedures across all aspects of benefits management, with a strong emphasis on negotiation, is preferred.
Bilingual candidates who can communicate in Spanish are preferred.
For candidates working in-person or remotely in specified locations, the salary range for this position is $77,028 to $132,048.
Locations:
California; District of Columbia (Washington, DC); Nevada; New York.
In addition to the salary, Elevance Health provides a comprehensive benefits package, including incentive and recognition programs, equity stock purchase options, and 401k contributions (all benefits are subject to eligibility requirements).
The salary offered for this position is determined based on various legitimate, non-discriminatory factors established by the company.
The company is fully committed to ensuring equal pay opportunities for equal work, regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
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