Clinical Fraud Investigator II

Job Title Clinical Fraud Investigator II Location & Hybrid Work Policy This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. PLEASE NOTE: This position is not eligible for current or future VISA sponsorship. Job Purpose The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. Responsibilities 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 to identify opportunities for fraud and abuse prevention and control. Review 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 Qualifications 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, Experiences and Competencies Advanced Excel skills, including Pivot Tables. 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. #J-18808-Ljbffr