Investigator I

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Anticipated End Date: 2026-06-30 Position Title: Investigator I Job Description: Investigator I Hybrid 1 : This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center-connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. Schedule: Monday-Friday, standard business hours (8:00 AM-5:00 PM), with flexibility in start and end times based on operational needs and mutual agreement. The Investigator I will be responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. How you will make an impact: Review and triage investigative leads generated by claims-based anomaly detection, prioritizing work based on probability of FWA and benefit risk to the client. Conduct comparative claims/data analysis to determine whether aberrant billing patterns warrant an allegation and investigation (e.g., overutilization, usage spikes, upcoding; outlier comparison to similar/same providers). Draft investigation recommendations for client approval , including: allegation statement; evidence/artifacts from analysis; and an investigation plan covering targets (codes/groupings/providers), steps (records requests/surveys/interviews), scope (sample size/date ranges), affected claims universe, and anticipated financial impact. Create and maintain digital case records that clearly define investigation scope and contain all case artifacts/collateral, including client requests/approvals and the investigation plan used as the investigation roadmap. Execute investigation plans by requesting and reviewing medical records, performing additional data/evidence collection as warranted, and storing investigation steps and communications in the digital case record. Ensure compliance with client-approval requirements , including obtaining written client approval before any provider/member-facing requests, surveys, or interviews and before changes in flagged provider status. Prepare comprehensive findings reports that document founded/unfounded dispositions, cite defensible evidence from records and data collected, and recommend next steps (remediation vs. referral to law enforcement), including a request for client approval to proceed. Support approved remediation activities , including issuing provider notification of findings with required behavior changes and coordinating remediation options (education + post-pay tracking; prepayment monitoring; overpayment recovery referral Coordinate with clinical auditors during prepayment monitoring (PPR) by supporting targeted audit workflows and understanding routing outcomes (approve/pay, partial denial, full denial) and program completion/limitation criteria. Minimum Requirements: 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. Preferred Skills, Capabilities and Experiences: At least 2 years of investigative/audit experience in healthcare FWA/SIU, payment integrity, compliance investigations, or a closely related environment Strong claims analytics capability : experience performing comparative/outlier analysis and translating trends into a clear allegation narrative with defensible supporting artifacts (e.g., data pulls, comparisons, trend summaries). Medical record review and synthesis experience , including summarizing record findings into investigative conclusions and formal written reports. Demonstrated case management discipline : building/maintaining complete digital case files with communications, evidence, investigation steps, and approval trails. Experience drafting investigat

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