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Clinical Fraud Investigator II

Company: Anthem, Inc
Location: Midland
Posted on: June 12, 2021

Job Description:

Description SHIFT: Day JobSCHEDULE: Full-time Your Talent. Our Vision. At Anthem, Inc., its a powerful combination, and the foundation upon which were 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. The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. Primary duties may include, but are not limited to: + Conducts data mining activities using available tools and internal data warehouse. + Performs comprehensive analysis and clinical evaluation of the collected data. + Performs in-depth investigations on identified providers as warranted. + Examines claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. + Researches new healthcare related questions as necessary to aid in investigations. + Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern. + Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. + Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice. Assists with training of new associates. Qualifications + Requires an associate Degree in Nursing 4 years related experience including one year prior experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background. + Current certification as a Certified Professional Coder (AAPC or AHIMA) is preferred. Applicable to Colorado Applicants Only Annual Salary Range*: $61,600 - $77,000 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 Companys 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. An Equal Opportunity Employer/Disability/Veteran. Anthem, Inc. is ranked as one of Americas Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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. REQNUMBER: PS49521

Keywords: Anthem, Inc, Columbus , Clinical Fraud Investigator II, Other , Midland, Georgia

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