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Job Details

Clinical Fraud Investigator II - Any Anthem Office or Remote PS24588

Seven Hills, OH, United States

Posted on
Jul 11,2019

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Clinical Fraud Investigator II - Any Anthem Office or Remote (PS24588)

Location: United States


Requisition #: PS24588

Post Date: 4 hours ago

Your Talent. Our Vision. At **MEMBERS ONLY**SIGN UP NOW***., 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.

The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may post 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.
May train new associates.
Develops, designs and implements new or revised methods to improve the CIU operations.


Requires an associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA), at least 2 years related experience with 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.

**MEMBERS ONLY**SIGN UP NOW***. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.

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