Clinical Fraud Investigator II - Registered Nurse and CPC - Carelon Payment Integrity SIU at Elevance Health

Atlanta, Georgia, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA)
Minimum of 4 years related experience
Minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area (or any combination of education and experience providing equivalent background)

Responsibilities

Performs comprehensive analysis and clinical evaluation of collected data
Performs in-depth investigations on identified providers as warranted
Examines claims for compliance with relevant billing and processing guidelines and to identify 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
Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern
Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation
Identifies issues and/or entities that may pose potential risks associated with fraud and abuse

Skills

Registered Nurse

CPC

Claims Analysis

Fraud Investigation

Medical Records Review

Billing Guidelines

Data Analysis

Healthcare Compliance

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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