Clinical Fraud Investigator II (Remote)-PS34820

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 benefits companies and a Fortune Top 50 Company.
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.

Requires an associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA), 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.Ideal candidate will possess a Degree in Nursing with a minimum of 2 years of coding experience . Current Certified Professional Coder is preferred.AnEqualOpportunityEmployer/Disability/Veteran
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