Job Description

Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risks associated with fraud and abuse.

How you will make an impact:

• 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 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 Requirements:

• Requires an 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, Qualifications, and Experiences:

Fraud and Abuse experienced Nurse with a CPC are highly desired.

For candidates working in person or virtually in the below location(s), the salary range for this specific position is $65,968 to $124,992. Locations: California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Washington State

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.

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