Clinical Fraud Investigator Role for Healthcare Professionals

6 days ago


Mason, Ohio, United States Elevance Health Full time

At Elevance Health, we are seeking a skilled Clinical Fraud Investigator to join our team. This role is ideal for healthcare professionals with experience in fraud and abuse investigations.

About the Job

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

Key Responsibilities
  • Conduct data mining activities using available tools and internal data warehouse.
  • Perform comprehensive analysis and clinical evaluation of collected data.
  • Examine claims for compliance with relevant billing and processing guidelines.
  • Identify opportunities for fraud and abuse prevention and control.
Requirements

To be successful in this role, you will require:

  • An Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA).
  • A minimum of 4 years related experience, including at least 1 year in a Clinical Fraud and Abuse Investigation area.
Salary and Benefits

We offer a competitive salary range of $70,140 to $120,240 based on location and experience. In addition to your salary, we provide a comprehensive benefits package, including medical, dental, vision, short and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.

Work Environment

We operate in a hybrid workforce strategy, requiring associates to work at an Elevance Health location at least once per week. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.



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