Anthem, Inc. Investigator I/ II- Job Family in Portland, Maine
SHIFT: Day Job
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 care 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 skillset relative to the qualifications listed for this position.
This is a remote position near any Anthem office (Indianapolis, IN preferred)
Responsible for investigating assigned cases, collecting, researching, and analyzing claim data 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.
Responsible for the identification, investigation and development of 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 identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state.
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.
- Requires a BA/BS and minimum of 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.
- Requires a BA/BS and minimum of 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.
Health insurance, law enforcement experience preferred.
Applicable to Colorado Applicants Only
Annual Salary Range*: 61,840.00-77,300.00
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
- The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
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, Inc. has 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 Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.