Clinical Fraud Investigator II

The Elevance Health Companies, Inc.; Atlanta (GA); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Health insurance

Paid time off

401(k) + match

Stock purchase plan

Wellness programs

Job summary

Elevance Health is seeking a Clinical Fraud Investigator II to analyze clinical data and conduct investigations into potential fraud and abuse. The role supports collaboration across the Special Investigation Unit and other internal teams in a hybrid in-office/remote environment.

The ideal candidate will have a nursing background or CPC certification with 4+ years of related experience, including fraud investigation exposure, and strong analytical capabilities to identify billing irregularities.

Qualifications

• Requires an Associate Degree in Nursing and/or Certified Professional Coder certification with 4+ years of related experience.
• Includes at least 1 year of clinical fraud and abuse investigation experience.

Responsibilities

• 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.

Skills

Investigations

Analytical thinking

Critical thinking

Attention to detail

Education

Associate Degree in Nursing

Certified Professional Coder (AAPC or AHIMA)

Job description

Anticipated End Date: 2026-10-19

Position Title: Clinical Fraud Investigator II

Job Description

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.

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

• Registered Nurse Certified Professional Coder (AAPC or AHIMA)
• Investigations background
• Applied analytical and critical‑thinking skills
• #EHS

Job Level: Non-Management Exempt
Workshift: 1st Shift (United States of America)
Job Family: FRD > Investigation

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success – for our consumers, our associates, our communities and our business.

Compensation & Benefits

• market‑competitive total rewards that include merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs (unless covered by a collective bargaining agreement)
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources
• to name a few

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member‑facing roles to become vaccinated against COVID‑19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.

We are a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

Join our Talent Community and stay connected with company news, information, and future job opportunities. Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner.

Our nearly 100,000 associates serve approximately 100M+ people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry‑leading capabilities and a digital platform for health.

Please visit the Contract Worker Community Page. Elevance Health is an Equal Opportunity Employer/Disability/Veterans.