Clinical Fraud Investigator II

Clinical Fraud Investigator II Locations: 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. How You Will Make An Impact Perform comprehensive analysis and clinical evaluation of the collected data. Perform in‑depth investigations on identified providers as warranted. Examine claims for compliance with relevant billing and processing guidelines and identify opportunities for fraud and abuse prevention and control. Review and conduct retrospective analysis of claims and medical records prior to payment. Research new healthcare‑related questions as necessary to aid in investigations. Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern. Recommend 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 minimum 4 years related experience, including minimum 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience that would provide an equivalent background. Preferred Skills, Experiences and Competencies Advanced Excel skills, including Pivot Tables. 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. The health of our associates and communities is a top priority. We require all new candidates in certain patient/member‑facing roles to become vaccinated against COVID‑19 and Influenza. 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 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. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. #J-18808-Ljbffr