Investigator I

This position will work a hybrid model (remote and office), 1-2 times per week. The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.The Investigator I is responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices.How You Will Make An Impact• Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.• 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.• Effectively establish rapport and on-going working relationship with law enforcement.• 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.• Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.• Preparation of final case reports and notification of findings letters to providers.• Receive offers of settlement for review and discussion with management.• Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.Minimum Requirements• Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.Preferred Skills, Capabilities, And Experiences• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.• Excel knowledge a plus.• Experience within Managed Care Organization a plus.