Investigator Lead

Location: Hybrid – This role requires associates to be in the office 1–2 days per week, fostering collaboration and connectivity while providing flexibility to support productivity and work-life balance. Alternate locations may be considered. Candidates must reside within a reasonable commuting distance from the posting location(s) unless an accommodation is granted as required by law.

About the role

The Investigator Lead provides leadership and guidance to the Special Investigations Unit team in investigating, collecting, researching, and analyzing billing data to detect fraudulent, abusive, or wasteful activities and practices. This role applies sound judgment in investigative methodologies, evaluates market trends, and recommends focused investigative activities related to Fraud, Waste, and Abuse within the healthcare industry.

Responsibilities

• Assist the team manager with administration and operational activities within the Special Investigations Unit, including coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management.
• Direct day-to-day operations as assigned by management.
• Provide training and conduct data analysis using appropriate system tools to detect fraudulent, abusive, or wasteful payments to providers and subscribers.
• Prepare statistical and financial analyses and reports to document findings, maintaining up-to-date case files for management review.
• Prepare final reports and notification of findings letters suitable for distribution to providers and legal counsel.
• Create and present settlement offers for provider issues for review and approval by management and/or legal.
• Communicate orally and in writing with internal and external customers regarding findings.
• Assist management and provide recommendations in support of policy and procedure development to prevent loss of company assets.
• Prepare and deliver training to internal and external entities.
• Develop and maintain rapport and cooperation with Federal, State, and local law enforcement and regulatory agencies to assist in investigative efforts.
• Represent the Company in court proceedings regarding research findings.
• Provide guidance to investigators and other SIU staff in the development of criminal and recovery cases.
• Lead SIU projects or initiatives.

Requirements

• Requires a BA/BS and a minimum of 8 years of related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience that provides an equivalent background.

Preferred Qualifications

• Professional certification such as CFE, AHFI, CPC, Paralegal, RN, JD, or other job-related designation.
• Experience investigating Medicaid market trends in Colorado, Kansas, Arkansas, and Virginia.
• Knowledge of Plan policies and procedures in all facets of benefit programs management, with an emphasis on negotiation.

Pay

For candidates working in person or virtually in Norfolk, Virginia, the salary range for this position is $87,280 to $130,920. The salary offered is based on legitimate, non-discriminatory factors set by the Company, including geographic location, work experience, education, and skill level.

Benefits

• Comprehensive benefits package, including medical, dental, vision, short- and long-term disability, and 401(k) with company match.
• Incentive and recognition programs.
• Equity stock purchase plan.
• Paid holidays and Paid Time Off (PTO).
• Life insurance, wellness programs, and financial education resources.

Schedule

Elevance Health operates under a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, with specific onsite requirements discussed during the hiring process.