Pharmacy Investigator Senior

Join to apply for the Pharmacy Investigator Senior role at Elevance Health

Hybrid
:
This role requires associates to be in-office 1‑2 days per week, fostering collaboration and enabling flexibility. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance will not be considered unless an accommodation is granted as required by law.

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.
• Independent identification and development of enterprise‑wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state.
• Interface internally with senior‑level management and legal department throughout the investigative process.
• Assistance in training of internal and external entities.
• Development of policy and/or procedures to prevent loss of company assets.
• Representation of the company in court proceedings regarding research findings.
• Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.
• Maintenance of a high degree of rapport and cooperation with federal, state and local law‑enforcement and regulatory agencies that assist investigative efforts.

Minimum Requirements:

• BA/BS and a minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or an equivalent combination of education and experience.

Preferred Skills, Capabilities, and Experiences:

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or Law Enforcement preferred.
• Pharmacy claims, records and investigations experience strongly preferred.
• Pharmacy technician license and/or experience preferred.
• Formulary, clinical rules, pharmacy claims analysis, and/or prior authorization experience for a pharmacy benefit manager or health plan strongly preferred.
• Knowledge of plan policies and procedures in all facets of benefit programs management with a heavy emphasis on negotiation preferred.
• Proficiency with Microsoft Office products, most notably expertise in Excel, Word, PowerPoint, Teams, and Outlook strongly preferred.
• One year or more Excel experience working with large data files and other general reporting tools preferred.
• Experience with background research, data mining and data analysis strongly preferred.
• Ability to communicate information clearly and concisely, both orally and in writing, in a professional and legal environment strongly preferred.

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.

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.

At Elevance Health, we are creating a culture designed to advance our strategy while enabling personal and professional growth for our associates. Our values and behaviors are the roots of our culture.

We offer a range of 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 and financial education resources.

Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week. Specific requirements and expectations for time onsite will be discussed as…