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Investigator I, II or Senior-PS16715

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Fraud
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PS16715 Requisition #
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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 benefits companies and a Fortune Top 50 Company.

This is a job family posting considering level I, II, or Senior. The Hiring Manager will determine level based on skills and experience. 
Preferred location: Any Anthem location

The Investigator I, II, or Sr. is responsible for the independent identification, investigation and development of complex 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 independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state.   
  • 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. 
  • May be called upon to represent the Company in court proceedings regarding research findings. 
  • Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting.  
  • Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.  
Investigator I
  • Requires BA/BS degree, 2+ years related experience preferably in health insurance, law enforcement; or any combination of education and experience, which would provide an equivalent background.
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.
Investigator Sr. 
  • Requires BA/BS degree, 5+ years related experience in healthcare insurance and healthcare insurance investigation, law enforcement or any combination of education and experience which would provide an equivalent background. 
  • Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.  
  • Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers.
 
An Equal Opportunity Employer/Disability/Veteran

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Metrics & Data

Leverage your talents to make a difference in people's lives, by providing innovative, data-driven solutions that can measure and improve consumer's health.

Anthem metrics and data associates focus on creating innovative, data-driven solutions that can measure and track progress in our members’ health. Collaborate with internal and external experts to develop metrics-supported strategies for improving measurements and processes.

Enable physicians and hospitals to improve care with valuable information that improves care quality and affordability. Join us and help provide tools to help consumers make better decisions, as we create a simpler, more affordable, more accesible healthcare system.

Metrics and data associates at Anthem:

  • Develop statistical models and functional means for measuring the quality of health care members receive annually
  • Provide members with useful, powerful tools for self-evaluation and tracking of health issues and risk factors
  • Show initiative and make key decisions with the potential to dramatically influence patient outcomes and positively impact peoples' lives
  • Create thoughtful solutions that engage and empower members to make more informed decisions about their health and health care
  • Serve as a catalyst to improve the essential relationship between patient and health care provider
  • Leverage metrics and data to deliver resources that help overcome traditional coverage barriers such as education, literacy and language

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