Job Description

Investigator II

Supporting the Payment Integrity line of business, this role is hybrid 1, requiring associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. Alternate locations may be considered.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is committed to recovering, eliminating and preventing unnecessary medical-expense spending.

The Investigator II is responsible for the identification, investigation, and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims.

How you will make an impact:

• Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional, and pharmacy claims.
• Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business, and/or state.
• Effectively establish rapport and on-going working relationship with law enforcement.
• May interface internally with Senior level management and legal department throughout investigative process.
• May assist in training of internal and external entities.
• Assists in the development of policy and/or procedures to prevent loss of company assets.

Minimum Requirements:

• Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities & Experiences:

• Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
• Health insurance, law enforcement experience preferred.
• Experience with Excel spreadsheets highly preferred.

For candidates working in person or virtually in the below location, the salary range for this specific position is $72,912 to $109,368.

Locations: Maryland.

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set 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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

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