Pharmacy Investigator I

Anticipated End Date:

2026-02-18

Position Title:

Pharmacy Investigator I

Job Description:

Pharmacy Investigator I

Hybrid: 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 if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Pharmacy 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:

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or Law Enforcement. 

• Pharmacy claims, records and investigations, experience.

• Pharmacy technician license and/or experience.

• Experience working with formulary, clinical rules, pharmacy claims analysis, and/or prior authorization experience for a pharmacy benefit manager or health plan.

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

• Proficiency with Microsoft Office products, most notably expertise in Excel for reporting, Word, PowerPoint, Teams, and Outlook.

• One year or more Excel experience working with large data files and other general reporting tools.

• Experience with background research, data Mining and data analysis.

• Ability to communicate information clearly and concisely, both orally and in writing, in a professional and legal environment.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $63,000 to $103,500.

Locations: Cerritos, CA and Las Vegas, NV

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 ear