Investigator Lead

Investigator Lead

Location:

Hybrid1:
This role requires associates be in the 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.

The Investigator Lead is responsible for providing leadership and guidance to the Special Investigations Unit team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Provides comprehensive sound judgment in the application of various investigative methodologies to team members and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating Fraud, Waste and Abuse within the healthcare industry.

How you will make an impact:

• Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day-to-day operations as assigned by management.
• Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers.
• Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review.
• Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel.
• Creates and presents settlement offers for provider issues for review and approval by management and/or legal.
• Communicates orally and in writing with all customers, internal and external, regarding findings.
• Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets.
• Prepares and delivers training to internal and external entities.
• Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.
• Represents the Company in court proceedings regarding research findings.
• Provides guidance to investigators and other SIU staff in the development of criminal and recovery cases.
• Leads SIU projects or initiatives.

Minimum Requirements:

• Requires a BA/BS and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.
• Experience investigating Medicaid market trends in Colorado, Kansas, Arkansas, and Virginia preferred
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

For candidates working in person or virtually in the below locations, the salary
* range for this specific position is $87,280 to $130,920

Location(s):
Norfolk, Virginia

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.