Anticipated End Date:2026-07-22
Position Title:Clinical Fraud Investigator II
Job Description:Clinical Fraud Investigator IILocations: 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.
The
Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.
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:- Advanced Excel skills, including Pivot Tables
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.
