Description

The Lead Investigator - Idaho 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.

Primary duties may include, but are not limited to:

• 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.

Position 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.
• 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.
• Must live in Idaho.
• Strong healthcare investigative experience is preferred.
• Must be able to communicate effectively.
  

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

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.

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. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. 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 ability@icareerhelp.com for assistance.