Investigator II - Elevance Health : Job Details

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 certificate...Investigator, Insurance, Healthcare