Investigator I, II, Sr. - Remote (Texas Preferred) (PS27604)

Investigator I, II, Sr. - Remote (Texas Preferred) (PS27604)

18 Sep 2024
Arizona, Tucson 00000 Tucson USA

Investigator I, II, Sr. - Remote (Texas Preferred) (PS27604)

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Investigator I, II, Sr. - Remote (Texas Preferred) (PS27604)Location: Texas, United StatesNewRequisition #: PS27604Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.Investigator I, II or Sr. - Remote (Texas Preferred)This position can be filled at the Investigator I, II, or Sr. level depending on qualifications and is at the managers discretion.Investigator IResponsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. Primary duties may include, but are not limited to:

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

Investigator IIResponsible 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. Primary duties may include, but are not limited to:

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.

Must be able to 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. Health insurance, law enforcement experience preferred.

Investigator Sr.Responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Primary duties may include, but are not limited to:

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

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.

May be called upon to represent 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.

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.

QualificationsInvestigator I

Requires BA/BS, 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

Minimal travel may be required

Medicaid, fraud, waste, and abuse investigation experience preferred

Investigator II

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

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.

Minimal travel may be required

Medicaid, fraud, waste, and abuse investigation experience preferred

CPC is an asset

Data analysis experience is an asset

Investigator Sr.

Requires BA/BS degree 5+ years related experience in healthcare insurance and healthcare insurance investigation, law enforcement or any combination of education and experience which would provide an equivalent background.

Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.

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

Minimal travel may be required

Medicaid, fraud, waste, and abuse investigation experience preferred

CPC is an asset

Data analysis experience is an asset

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

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Job Details

  • ID
    JC2713627
  • State
  • City
  • Full-time
  • Salary
    N/A
  • Hiring Company
    Anthem, Inc
  • Date
    2019-09-19
  • Deadline
    2019-11-17
  • Category

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