Investigator II - Behavioral Health

About the role

The Investigator II - Behavioral Health is responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. This role requires associates be in the office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance.

Responsibilities

• 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.
• Identify and develop 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.
• Interface internally with Senior level management and legal department throughout investigative process.
• Aid in the training of internal and external entities.
• Aids in the development of policy and/or procedures to prevent loss of company assets.

Requirements

• BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background.
• Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
• Health insurance, law enforcement experience preferred.
• Behavioral Health FWA Investigation experience preferred.

Preferred Skills, Capabilities, and Experiences

• Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
• Health insurance, law enforcement experience preferred.
• Behavioral Health FWA Investigation experience preferred.

Benefits

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Pay

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.

Schedule

Location(s): Virginia