Investigator II

Anthem, Inc.
Full time
Other
United States
Hiring from: Anywhere

Investigator II


Location:

Job Family: Fraud

Req #: PS37211


Description


SHIFT: Day Job

SCHEDULE: Full-time


Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.


This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.


Location: This position can be located at any Anthem Office or can be Remote


Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Primary duties may include, but are not limited to:



  • 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 identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state.

  • Must be able to effectively establish rapport and on-going working relationship with law enforcement.

  • 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.


Qualifications



  • Requires BA/BS degree, 3+ years related experience; or any combination of education and experience, which would provide an equivalent background.

  • Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.

  • Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

  • Health insurance, law enforcement experience preferred.


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