Investigator II

Elevance Health; Mason (OH); Hybrid; USD 65,000 - 85,000; Full time

Job summary

Elevance Health is seeking an Investigator II to support its Payment Integrity line of business. This hybrid role, requiring 1-2 days in-office, focuses on identifying and investigating healthcare fraud. Ideal candidates will have a BA/BS and relevant experience, with opportunities to impact multiple health plans and collaborate with law enforcement.

Benefits

Paid Time Off

401(k) + match

Incentive bonus programs

Medical, dental, vision benefits

Wellness programs

Qualifications

• Minimum of 3 years related experience in investigation.
• Fraud certification preferred (CFE, AHFI, AAPC).
• Knowledge of healthcare policies and procedures.

Responsibilities

• Investigate cases of fraud to recover funds.
• Conduct claim reviews for coding accuracy.
• Develop and implement investigative policies.

Skills

Fraud Investigation

Data Mining

Coding

Education

BA/BS degree

Tools

Excel

Job description

Anticipated End Date:

2025-06-13

Position Title:

Investigator II

Job Description:

Investigator II

Supporting the Payment Integrity line of business

Location: Hybrid 1 : This role requires associates to be in-office1-2 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.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Investigator II is responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims.

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

• Effectively establish rapport and on-going working relationship with law enforcement.

• 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.

Minimum Requirements

• Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities & Experiences

• Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.

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

• Health insurance, law enforcement experience preferred.

• Experience with Excel spreadsheets highly preferred.

Job Level:

Non-Management Exempt

Workshift:

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 Fortune 25 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.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and 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 and 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 may contact [e-mail] for assistance. 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.