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Senior Investigator
Columbus, GA Senior Investigator (Investigator Sr) - Remote/Office Hybrid Model • Location: Work from home and office (within 50 miles of **MEMBERS ONLY**SIGN UP NOW*** PulsePoint locations) • Job Reference: JR129194 • Date Posted: 10/31/2024 • Anticipated Date Close: 11/14/2024 • Apply Now Carelon Payment Integrity, a member of the **MEMBERS ONLY**SIGN UP NOW*** family of companies, is seeking a Senior Investigator to join their team. This individual will work remotely and in the office, living within 50 miles of one of our **MEMBERS ONLY**SIGN UP NOW*** PulsePoint locations. The ideal candidate will have experience in health insurance and healthcare insurance investigation, law enforcement, or a related field. As a Senior Investigator, you will be responsible for identifying and investigating complex cases of healthcare fraud, recovering corporate and client funds paid on fraudulent claims. You will also be responsible for conducting claim reviews, coding, data mining, and entity review, as well as collaborating with internal and external entities and assisting in the development of policies and procedures to prevent loss of company assets. Key Responsibilities: • Conduct claim reviews and investigations for appropriate coding, data mining, and entity review • Independently identify and develop healthcare investigations that may impact multiple company health plans, lines of business, and/or states • Interface with senior level management and legal department throughout the investigative process • Assist in training internal and external entities • Develop and maintain relationships with law enforcement and regulatory agencies • Represent the company in court proceedings regarding research findings Minimum Requirements: • BA/BS degree and a minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement, or a related field • Knowledge of health insurance policies, claims handling, and provider network contracting • Excellent communication and interpersonal skills Preferred Skills, Capabilities, and Experiences: • Prior investigative experience and skills strongly preferred • Proficient in Microsoft Excel and its functionality • Ability to manage and organize priorities and a varied caseload effectively • Professional certification (CFE, AHFI, CPC, Paralegal, RN, JD) preferred • Knowledge of plan policies and procedures, with a focus on negotiation **MEMBERS ONLY**SIGN UP NOW*** is a Fortune 25 healthcare company dedicated to improving lives and communities by making healthcare simpler. We are looking for passionate leaders at all levels who are committed to making a positive impact on our members and the communities we serve. At **MEMBERS ONLY**SIGN UP NOW***, we are creating a culture that fosters personal and professional growth for our associates. Our values and behaviors are the foundation of our culture and drive our shared success for our consumers, associates, communities, and business. We offer a range of competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs, as well as medical, dental, vision, and disability benefits. As part of our Hybrid Workforce Strategy, this role will work from home and at an **MEMBERS ONLY**SIGN UP NOW*** location at least once a week. Candidates must reside within 50 miles or a 1-hour commute of an **MEMBERS ONLY**SIGN UP NOW*** location. The health and safety of our associates and communities are our top priority, and we require all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19. **MEMBERS ONLY**SIGN UP NOW*** 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. If you require accommodation during the job application process, please contact **MEMBERS ONLY**SIGN UP NOW*** for assistance. |
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