Investigator Senior

Anticipated End Date:

2025-07-10

Position Title:

Investigator Senior

Job Description:

Investigator Senior

Location Hybrid 1: This role requires associates to be in-office 1 - 2  days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

The Investigator Senior position is responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Candidate will need a strong Medicare/Medicaid background with a focus on Pharmacy.

How you will make an impact:

• 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 independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state. 

• 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.

• May be called upon to represent the Company in court proceedings regarding research findings.

• Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. 

• Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts. 

Minimum Requirements

• Requires a BA/BS and minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Pharmacy investigation experience is highly preferred.

• Professional certification of Pharm Tech, Pharmacist, CFE, AHFI, CPC, Paralegal, RN, JD or other job-related designation preferred. 

• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

• Claims & NDC Code experience preferred.

• Data mining experience preferred.

• Drug related investigation experience highly preferred.

• Strong analytical & problem solving experience preferred.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $78400 to $141120

Locations: California; Colorado; Nevada; 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 Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Job Level:

Non-Management Exempt