Clinical Fraud Investigator

At Elevance Health, we are dedicated to providing high-quality healthcare services to our clients. As a Clinical Fraud Investigator, you will play a crucial role in ensuring the integrity of our operations by detecting and preventing fraudulent activities. We are seeking a highly skilled and experienced individual who is passionate about fighting healthcare fraud and has a strong understanding of healthcare regulations. If you have a keen eye for detail, excellent analytical skills, and are driven by a desire to make a positive impact in the healthcare industry, we encourage you to apply for this exciting opportunity. Join our dynamic team and help us maintain the highest standards of ethical and compliant practices.

1. Conduct thorough investigations to identify potential cases of healthcare fraud, waste, and abuse.
2. Review medical records, claims data, and other relevant documentation to detect fraudulent activities.
3. Utilize various investigative techniques and tools to gather evidence and build a strong case against suspected fraudsters.
4. Collaborate with internal and external stakeholders, including law enforcement and regulatory agencies, to share information and coordinate efforts to combat fraud.
5. Stay up-to-date with healthcare regulations and industry trends to identify emerging fraud schemes and develop effective prevention strategies.
6. Prepare detailed investigative reports and recommendations for management and legal proceedings, if necessary.
7. Conduct interviews and collect statements from witnesses and suspects to gather information and evidence.
8. Maintain confidentiality and handle sensitive information with discretion and professionalism.
9. Assist in developing and implementing fraud prevention and detection policies and procedures.
10. Provide training and guidance to other team members on identifying and reporting potential fraud.
11. Participate in audits and compliance reviews to identify potential areas of vulnerability and make recommendations for improvement.
12. Testify in court or administrative hearings as an expert witness, if needed.
13. Represent the company in a professional and ethical manner at all times.
14. Contribute to a positive and collaborative work environment by maintaining open communication and actively participating in team meetings and discussions.
15. Continuously evaluate and improve investigative processes and techniques to ensure maximum efficiency and effectiveness.

According to JobzMall, the average salary range for a Clinical Fraud Investigator in Topeka, KS, USA is $52,000-$85,000 per year. This can vary depending on factors such as experience, qualifications, and the specific employer.

Elevance Health, Inc. is an American health insurance provider. The company's services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated companies such as Anthem Blue Cross and Blue Shield, Empire BlueCross BlueShield in New York State, Anthem Blue Cross in California,Wellpoint, and Carelon.It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2022, the company had 46.8 million members within their affiliated companies' health plans. Prior to June 2022, Elevance Health was named Anthem, Inc.