Investigator I
Elevance Health

Job Info

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Investigator I

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations in the EST timezone.

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.
• 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:

• Prior investigative experience and skills strongly preferred.
• Strong analytic skills preferred.
• Ability to manage and organize priorities and a varied caseload effectively preferred.
• Strong communication skills preferred.
• Proficient in Microsoft Excel strongly preferred.

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