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Elevance Health
Clinical Fraud Investigator IIElevance Health • Grand Prairie, TX, United States
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Clinical Fraud Investigator II

Clinical Fraud Investigator II

Elevance Health • Grand Prairie, TX, United States
12 days ago
Job type
  • Full-time
Job description

Clinical Fraud Investigator II

Clinical Fraud Investigator II

Locations: 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.

PLEASE NOTE: This position is not eligible for current or future VISA sponsorship.

The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How you will make an impact:

  • Performs comprehensive analysis and clinical evaluation of the collected data.
  • Performs in-depth investigations on identified providers as warranted.
  • Examines claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.
  • Review and conducts retrospective analysis of claims and medical records prior to payment.
  • Researches new healthcare related questions as necessary to aid in investigations.
  • Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.
  • Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

Minimum Requirements:

Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and minimum of 4 years related experience, including minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Experiences and Competencies:

  • Advanced Excel skills, including Pivot Tables

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: FRD > Investigation

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Clinical Fraud Investigator II • Grand Prairie, TX, United States

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