What are the responsibilities and job description for the Investigator I position at Elevance Health?
Location:
This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on 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
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
Investigative experience preferred (e.g. health insurance, law enforcement).
Excel proficiency is strongly preferred; ability to run pivot tables and analyze large datasets.
Familiarity with CPT coding preferred.