Clinical Fraud Investigator II

Clinical Fraud Investigator II

Location: This position will work in a hybrid model (remote and office). The ideal candidate must live within 50 miles of our Elevance Health PulsePoint location listed in the requisition.

Work schedule: M-F normal business hours

The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How will you make an impact:

Conducts preliminary data mining activities using available tools. and internal data warehouse.

Performs comprehensive analysis and clinical evaluation of the collected data.

Performs in-depth investigations on identified providers and members as warranted.

Examines claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.

Review and conducts analysis of claims and dental medical records as related prior to payment.

Research new healthcare related questions as necessary to aid in investigations.

Collaborates with the Special Investigation Unit, Oral Health Analytics department 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.

Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice.

Assists with training of new associates.

Minimum Requirements:

Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and minimum of 4 years related experience, including minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

Strongly prefer a current unrestricted Dental Hygienist or a Dental Assistant certification and a minimum of 5 years clinical experience.

Preferred experience in a Clinical Fraud and Abuse Investigation area, dental office administration, dental claim submission: or any combination of education experience, which would provide an equivalent background.

For candidates working in person or remotely in the below location(s), the salary range for this specific position is $66,800 to $125,250.

Locations: California; Colorado; District of Columbia (Washington, DC); Maryland, Nevada; New York; Washington State

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 .

The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success – for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.