Clinical Fraud Investigator II

Location The Clinical Fraud Investigator II position requires associates to be in‑office 1‑2 days per week with flexibility for virtual work. Alternate locations may be considered for candidates residing within a commuting distance from an office. NOTE: This position is not eligible for current or future VISA sponsorship. Clinical Fraud Investigator II The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. How You Will Make an Impact Performs comprehensive analysis and clinical evaluation of the collected data. Performs in‑depth investigations on identified providers as warranted. Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control. Reviews and conducts retrospective analysis of claims and medical records prior to payment. Researches new healthcare‑related questions as necessary to aid in investigations. Collaborates with the Special Investigation Unit 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. Minimum Requirements Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and a minimum of 4 years related experience, including at least 1 year of experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience that provides an equivalent background. Preferred Skills, Experiences and Competencies Advanced Excel skills, including Pivot Tables. Benefits 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. Equal Employment Opportunity 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 View email address on click.appcast.io for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. #J-18808-Ljbffr Elevance Health