Investigator I or II - PS23565 Location: Indiana, United States Requisition : PS23565 Post Date: Jun 25, 2019 _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. _Please Note: This position may be filled at either the Investigator I or Investigator II level. Manager will determine level based upon the selected applicant's skill-set relative to the qualifications listed for this position._ The Investigator I or II is 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. 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 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. 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. _Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran._ Associated topics: crime scene, detective, fingerprint, inspector, investigate, investigation, investigative, investigator
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