- Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy 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.
- 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.
- 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.
- Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.
- 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.
- Bilingual candidate who can speak Spanish is preferred.
-
VP, Compliance
1 week ago
Wellvana Nashville, United StatesApply · Description · Who we are: · The healthcare system isn't designed for health. We're designed to change that. We're Wellvana, and we help doctors deliver life-changing healthcare. Through our elevated value-based care programs, we're revitalizing an antiquated system that's ...
-
Senior HUD Community Manager
5 days ago
Envolve Nashville, United StatesEnvolve Community Management, LLC owns and professionally manages apartment communities located in select markets throughout the southeastern United States. We are a company whose success is measured by our residents' satisfaction in making their apartment homes and community a g ...
-
Senior Casualty Desk Adjuster
4 days ago
The General Nashville, United States Regular, Full timeAt The General, we are seeking a Senior Casualty Desk Adjuster to investigate and maintain complex or highly complex casualty claims . You will determine liability, secure information, reviews coverages, arrange appraisals, and settle claims for us. · You will report to the Claim ...
-
VP, Compliance Officer
1 week ago
e CancerCare Nashville, United StatesJob Purpose: · This position is responsible for performing regulatory activities, providing analysis and support of the company's and programs compliance activities, and day-to-day administration of compliance issues. Works closely with Senior Management to ensure the organizatio ...
-
VP, Compliance Officer
1 week ago
Integrated Oncology Network Nashville, United StatesVP, Compliance Officer - must have Healthcare compliance experience · Job Title VP, Compliance Officer - must have Healthcare compliance experience Job ID Location Nashville, TN 37205 Other Location Description Job Purpose: · This position is responsible for performing regulatory ...
-
Sr Program Manager, Shipping
1 week ago
Amazon, Inc. Nashville, United States· Amazon's expanding Logistics products and services (e.g. Amazon Logistics, Global Specialty Fulfillment, and Amazon Delivery Technology) are creating new customer segments, including drivers, recipients, shippers, property managers, global sellers and storage owners. Shipping ...
-
Field Adjuster
3 days ago
The Jonus Group Nashville, United StatesFull job description · About us · A 76-year-old independent property & casualty claims adjusting company serving the US Southeast Region. We are looking for an experienced casualty claims adjuster to join our Nashville, TN office. As a Senior Casualty Claims Adjuster, you will be ...
-
VP, Compliance
2 days ago
Wellvana Nashville, United StatesApply · Description · Who we are: · The healthcare system isn't designed for health. We're designed to change that. We're Wellvana, and we help doctors deliver life-changing healthcare. Through our elevated value-based care programs, we're revitalizing an antiquated system tha ...
-
Staff Scientist
1 week ago
Meharry Medical College Nashville, United StatesThis position will be responsible for the programmatic and operational management of the NIH-NHGRI-funded Diversity Center for Genome Research (DCGR), working closely with the PI Dr. Shanker, project awardees and students. The position will set goals and timelines in working with ...
-
Safety Management System Coordinator
4 days ago
Nashville International Airport Nashville, United StatesAs infrastructure critical to the region's growth and prosperity, BNA is a vital asset for Middle Tennessee and serves as a gateway to Music City and beyond. According to a recent State of Tennessee study, in 2019 alone, BNA generated more than $9.9 billion in total economic impa ...
-
director of quality/patient safety
1 week ago
Nashville General Hospital Nashville, TN, United States· Nashville General Hospital is hiring a Full Time Director of Quality/Patient Safety for Quality Assurance in Nashville, Tennessee. · Shift: Day Shift · This Director of Quality/Patient Safety is primarily responsible for implementing, maintaining, and continuously evaluatin ...
-
Senior Claim Adjuster
1 day ago
FCCI Insurance Group Nashville, United StatesFCCI Insurance Group is a trusted provider of comprehensive property & casualty coverage in 20 states. We are a successful and growing organization built on the strength of our guiding principles. Doing the right thing and putting people first is the foundation for how we do busi ...
-
Senior Claim Adjuster
4 days ago
FCCI Insurance Group Nashville, United StatesFCCI Insurance Group is a trusted provider of comprehensive property & casualty coverage in 20 states. We are a successful and growing organization built on the strength of our guiding principles. Doing the right thing and putting people first is the foundation for how we do busi ...
-
Safety Management System Coordinator
3 days ago
Nashville International Nashville, United States· As infrastructure critical to the region's growth and prosperity, BNA is a vital asset for Middle Tennessee and serves as a gateway to Music City and beyond. According to a recent State of Tennessee study, in 2019 alone, BNA generated more than $9.9 billion in total economic i ...
-
Research Assistant 1
1 week ago
Vanderbilt University Medical Center Nashville, United States**Discover Vanderbilt University Medical Center:** Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is ...
-
Senior Revenue Cycle Analyst
1 week ago
US Heart & Vascular Nashville, United StatesUS Heart and Vascular is seeking a Senior Revenue Cycle Analyst to join our team in Tucson, AZ. · Senior Revenue Cycle Analyst · The Senior Revenue Cycle Analyst is responsible for analyzing and improving all aspects of revenue cycle management, including charge capture, billing ...
-
Research Assistant, Senior
1 week ago
Vanderbilt University Nashville, United StatesThe Senior Research Assistant will perform research in the biology of aging as a key contributor to a laboratory working to identify and understand interventions to ameliorate age-onset diseases and pathology. The Burkewitz lab uses a combination of molecular genetic, biochemical ...
-
Medical Science Liaison, Oncology Breast
4 days ago
Daiichi Sankyo Inc. Nashville, United States**Join a Legacy of Innovation 110 Years and Counting** · Daiichi Sankyo Group is dedicated to the creation and supply of innovative pharmaceutical therapies to improve standards of care and address diversified, unmet medical needs of people globally by leveraging our world-class ...
-
Safety Management System Coordinator
3 days ago
Metropolitan Nashville Airport Authority Nashville, United StatesAs infrastructure critical to the region's growth and prosperity, BNA is a vital asset for Middle Tennessee and serves as a gateway to Music City and beyond. According to a recent State of Tennessee study, in 2019 alone, BNA generated more than $9.9 billion in total economic impa ...
-
Senior Water Resources Engineer
1 week ago
NxT Level Nashville, United StatesSenior Water Resources Engineer · Hybrid in Nashville or Knoxville TN · Our client is currently seeking applications for the position of Senior Water Resources Engineer (Storm Water Engineer). In this role, you will be involved in various site investigations and assessments under ...
Investigator Senior - Nashville, United States - Elevance Health
Description
Job Description
:Investigator Senior
Supports the Payment Integrity line of business
Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles from one of our posted Elevance Health locations.
Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.
The Investigator Senior 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.
How will you make an impact:
Minimum Requirements
Preferred Qualifications
For candidates working in person or remotely 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.
Job Level:
Non-Management ExemptWorkshift:
Job Family:
FRD > InvestigationPlease 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. Elevance Health will also follow all relevant federal, state and local laws.
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 for assistance.
