Investigator I

Investigator I Hybrid 1 : 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 accommodation is granted as required by law. Schedule: Monday–Friday, standard business hours (8:00 AM–5:00 PM), with flexibility in start and end times based on operational needs and mutual agreement. The Investigator I will be responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. How you will make an impact Review and triage investigative leads generated by claims-based anomaly detection, prioritizing work based on probability of FWA and benefit risk to the client. Conduct comparative claims/data analysis to determine whether aberrant billing patterns warrant an allegation and investigation (e.g., overutilization, usage spikes, upcoding; outlier comparison to similar/same providers). Draft investigation recommendations for client approval , including: allegation statement; evidence/artifacts from analysis; and an investigation plan covering targets (codes/groupings/providers), steps (records requests/surveys/interviews), scope (sample size/date ranges), affected claims universe, and anticipated financial impact. Create and maintain digital case records that clearly define investigation scope and contain all case artifacts/collateral, including client requests/approvals and the investigation plan used as the investigation roadmap. Execute investigation plans by requesting and reviewing medical records, performing additional data/evidence collection as warranted, and storing investigation steps and communications in the digital case record. Ensure compliance with client-approval requirements , including obtaining written client approval before any provider/member-facing requests, surveys, or interviews and before changes in flagged provider status. Prepare comprehensive findings reports that document founded/unfounded dispositions, cite defensible evidence from records and data collected, and recommend next steps (remediation vs. referral to law enforcement), including a request for client approval to proceed. Support approved remediation activities , including issuing provider notification of findings with required behavior changes and coordinating remediation options (education + post-pay tracking; prepayment monitoring; overpayment recovery referral Coordinate with clinical auditors during prepayment monitoring (PPR) by supporting targeted audit workflows and understanding routing outcomes (approve/pay, partial denial, full denial) and program completion/limitation criteria. Minimum Requirements Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities and Experiences At least 2 years of investigative/audit experience in healthcare FWA/SIU, payment integrity, compliance investigations, or a closely related environment Strong claims analytics capability : experience performing comparative/outlier analysis and translating trends into a clear allegation narrative with defensible supporting artifacts (e.g., data pulls, comparisons, trend summaries). Medical record review and synthesis experience , including summarizing record findings into investigative conclusions and formal written reports. Demonstrated case management discipline : building/maintaining complete digital case files with communications, evidence, investigation steps, and approval trails. Experience drafting investigation plans and findings reports for client or stakeholder review/approval, including clear dispositioning (founded/unfounded) and recommended next steps. Working knowledge of common FWA indicators relevant to claims review (e.g., overutilization, upcoding, sudden spikes, outlier behavior compared to peers). Cross-functional collaboration experience , including partnering with clinical auditors and recovery/data-mining teams and making clean handoffs for remediation and recovery. Excellent written communication skills , especially for defensible documentation (allegations, evidence summaries, provider notification content, and remediation recommendations). For candidates working in person or virtually in the below locations, the salary* range for this specific position is $61,200 to $76,500. Location: Columbus, OH. 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 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. 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. 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