Investigator I - Carelon Payment Integrity at Elevance Health in Mason, Ohio

Job Description:

Investigator I - Carelon Payment Integrity




Location: The ideal candidate will live within 50 miles of one of our OH, TN, or IN offices and will work on a hybrid work model (1-2 days per week in the office).



Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate, and prevent unnecessary medical-expense spending.


The Investigator I is responsible for investigating assigned cases, collecting, researching, and analyzing claim data to detect fraudulent, abusive, or wasteful activities/practices.



How you will make a difference:

• 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.

• 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.

• Experience using Excel strongly preferred.