Sr Investigator at Elevance Health

Indianapolis, Indiana, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

BA/BS degree
Minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience providing an equivalent background
Health insurance experience with understanding of health insurance policies, health insurance claims handling, and provider network contracting
Reside within a reasonable commuting distance from posting locations (Indianapolis, IN; Columbus, OH; Nashville, TN) unless accommodation granted

Responsibilities

Independent identification, investigation, and development of complex cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims
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
Independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business, and/or state
Interfacing internally with senior level management and legal department throughout the investigative process
Assisting in training of internal and external entities
Assisting in the development of policy and/or procedures to prevent loss of company assets
Representing the company in court proceedings regarding research findings
Developing and maintaining rapport and cooperation with Federal, State, and local law enforcement and regulatory agencies to assist in investigative efforts

Skills

Key technologies and capabilities for this role

claim reviewcoding analysisdata miningentity reviewhealthcare fraud investigationlaw enforcement referralproprietary claim systemsfacility claims reviewprofessional claims reviewpharmacy claims review

Questions & Answers

Common questions about this position

What is the work arrangement for this Sr Investigator role?

This is a hybrid role requiring associates to be in-office 1-2 days per week in locations such as Indianapolis, IN, Columbus, OH, or Nashville, TN, with flexibility for virtual work. Candidates must reside within a reasonable commuting distance from one of these office locations, unless an accommodation is granted.

What are the minimum education and experience requirements?

A BA/BS degree and a minimum of 5 years of related experience in healthcare insurance, healthcare insurance investigation, or law enforcement is required, or any combination of education and experience providing an equivalent background.

What preferred certifications or skills are mentioned for this position?

Preferred qualifications include professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD or other job-related designations, along with knowledge of plan policies, procedures, and negotiation skills.

What salary or compensation information is provided?

This information is not specified in the job description.

What experience makes a candidate stand out for this Sr Investigator role?

Health insurance experience with understanding of policies, claims handling, and provider contracting is required, while preferred candidates have certifications like CFE or CPC, and skills in negotiation and working with law enforcement.

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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