Job details
Job type full-time
Full job description
Description
Shift: day job
Schedule: full-time
Your talentOur visionAt 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 communitiesJoin 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.
Investigator lead
This is a remote position sitting near the las vegas, nv anthem office
Responsible for providing leadership and guidance to the special investigations unit team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practicesProvides comprehensive sound judgment in the application of various investigative methodologies to team members and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating fraud, waste and abuse within the healthcare industry.
Primary duties may include, but are not limited to:
Assisting the team manager with the administration and operational activities occurring within the special investigations unit; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day-to-day operations as assigned by management.
Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers.
Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review.
Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel.
Creates and presents settlement offers for provider issues for review and approval by management and/or legal.
Communicates orally and in writing with all customers, internal and external, regarding findings.
Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets.
Prepares and delivers training to internal and external entities.
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.
Represents the company in court proceedings regarding research findings.
Provides guidance to investigators and other siu staff in the development of criminal and recovery cases.
Leads siu projects or initiatives.
Qualifications
Minimum qualifications:
Requires a ba/bs and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience, which would provide an equivalent background.
Preferred qualifications:
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.
Ability to travel 10-15%
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, incHas been named as a fortune 100 best companies to work for®, is ranked as one of the 2020 world’s most admired companies among health insurers by fortune magazine, and a 2020 america’s best employers for diversity by forbesTo learn more about our company and apply, please visit us at careers.antheminc.comAn equal opportunity employer/disability/veteranAnthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all anthem positions.
