Senior Investigator

at Elevance Health in Wilmington, Delaware, United States

Job Description

WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Elevance Health requires a completed online application for consideration of employment for any position. We will never ask you for a credit card, send you a check, or ask you for payment as part of consideration for employment.

Senior Investigator

+ Job Family: FRD > Investigation

+ Type: Full time

+ Date Posted:Apr 17, 2024

+ Anticipated End Date:May 06, 2024

+ Reference: JR112660



+ Washington, Seattle

+ Minnesota, Mendota Heights

+ Minnesota, Gilbert

+ Louisiana, Metairie

+ New York, Middletown

+ Ohio, Seven Hills

+ New Jersey, Iselin

+ Ohio, Mason

+ New York, Latham

+ California, Walnut Creek

+ Kentucky, Louisville

+ Ohio, Columbus

+ Tennessee, Nashville

+ Michigan, Dearborn

+ Ohio, Cincinnati

+ Rhode Island, Smithfield

+ Florida, Tampa

+ Massachusetts, Woburn


+ North Carolina, Winston


+ New Hampshire, Manchester

+ District of Columbia, Washington

+ California, Costa Mesa

+ Delaware, Wilmington


+ Iowa, West Des Moines


+ Connecticut, Wallingford

+ Texas, Houston

+ Texas, Grand Prairie

+ Illinois, Chicago

+ Wisconsin, Waukesha



+ Maryland, Hanover

+ Missouri, St Louis


+ Florida, Miami

+ West Virginia, Charleston

+ Maine, South Portland

+ New Jersey, Morristown


Job Description

Senior Investigator

Schedule: 1-2 days per week in the office (Hybrid 1)

Location: This position will work a hybrid model (remote and office). The ideal candidate must live within 50 miles of one of our Elevance Health PulsePoint locations.

The Senior Investigator position is 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. Candidate will need a strong pharmacy investigation background.

How you will make an impact:

+ Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility and professional 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.

Minimum Requirements

+ Requires a BA/BS and minimum of 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.

Preferred Skills, Capabilities and Experiences:

+ Pharmacy investigation experience is highly preferred.

+ 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.

+ Intermediate to advance knowledge of Microsoft Excel strongly preferred.

+ For candidates working in person in the below locations, the salary* range for this specific position is $73,360 to $132,048.

+ Locations:? California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

+ 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.

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.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success – for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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 an acceptable explanation

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Job Posting: JC258580582

Posted On: Apr 19, 2024

Updated On: May 03, 2024

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