Location: This position will work in a hybrid model (remote and office). The ideal candidate must live within 50 miles of our Elevance Health PulsePoint location listed in the requisition.
Work schedule: M-F normal business hours
The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.
How will you make an impact:
Conducts preliminary data mining activities using available tools. and internal data warehouse.
Performs comprehensive analysis and clinical evaluation of the collected data.
Performs in-depth investigations on identified providers and members 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 analysis of claims and dental medical records as related prior to payment.
Research new healthcare related questions as necessary to aid in investigations.
Collaborates with the Special Investigation Unit, Oral Health Analytics department 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.
Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice.
Assists with training of new associates.
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, Capabilities and Experiences:
Strongly prefer a current unrestricted Dental Hygienist or a Dental Assistant certification and a minimum of 5 years clinical experience.
Preferred experience in a Clinical Fraud and Abuse Investigation area, dental office administration, dental claim submission: or any combination of education experience, which would provide an equivalent background.
For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $66,800 to $125,250.
Locations: California; Colorado; District of Columbia (Washington, DC); Maryland, Nevada; New York; Washington State
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 considered to be 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.
