Investigator Senior supports the Payment Integrity line of business. This position works a hybrid model (remote and office) with alternate locations considered. The ideal candidate must live within 50 miles of MO, NC, and TX PulsePoint locations. Carelon Payment Integrity, part of Elevance Health, focuses on recovering, eliminating, and preventing unnecessary medical-expense spending. The Investigator Senior independently identifies, investigates, and develops complex cases against healthcare fraud perpetrators to recover corporate and client funds paid on fraudulent claims. Requires health insurance experience with understanding of policies, claims handling, and provider network contracting. Responsibilities include claim reviews for coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for facility, professional, and pharmacy claims. The role involves developing enterprise-wide healthcare investigations impacting multiple health plans, lines of business, or states, interfacing with senior management and legal departments, assisting in training, developing policies to prevent asset loss, representing the company in court, and maintaining cooperation with law enforcement and regulatory agencies. Minimum requirements include a BA/BS and 5 years of related experience in healthcare insurance, investigation, or law enforcement, or equivalent education and experience. Preferred qualifications include professional certifications such as CFE, AHFI, CPC, Paralegal, RN, JD, or related designations, and knowledge of plan policies and benefit program management with negotiation emphasis.
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