Investigator I, II

Company: Anthem, Inc
Location: Grand Prairie
Posted on: May 3, 2021

Job Description:

Description SHIFT: Day Job SCHEDULE: Full-time Investigator I, II This position can be filled as an Investigator I or Investigator II depending on experience. This position can sit remotely nationwide. Investigator I Responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. Primary duties may include, but are not limited to: + Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers. + Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review. + Preparation of final case reports and notification of findings letters to providers. + Receive offers of settlement for review and discussion with management. + Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings. Investigator II 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. + Health insurance, law enforcement experience preferred. Qualifications Investigator I + Requires BA/BS, 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. + Proficient in Microsoft Excel is required. + Experience with healthcare fraud, waste, and abuse is preferred. + Understanding logic behind data mining. Investigator II + 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. + Proficient in Microsoft Excel is required. + Experience with healthcare fraud, waste, and abuse is preferred. + Understanding logic behind data mining.Applicable to Colorado Applicants OnlyAnnual Salary Range: $53,920 - $77,300 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be 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 Companys sole discretion, consistent with the law. 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, to name a few. Anthem, Inc. is ranked as one of Americas Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at . An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions. REQNUMBER: PS49526-Texas

Keywords: Anthem, Inc, Grand Prairie , Investigator I, II, Other , Grand Prairie, Texas