Clinical Fraud Investigator II – Registered Nurse and CPC – Carelon Integrity SIU

Job Description:

Clinical Fraud Investigator II – Registered Nurse and CPC – Carelon Payment Integrity SIU.

Location:

This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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 an accommodation is granted as required by law.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, formerly Payment Integrity, and is determined to recover, eliminate and prevent unnecessary medical‑expense spending. The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risks associated with fraud and abuse.

• Perform comprehensive analysis and clinical evaluation of the collected data.
• Perform in‑depth investigations on identified providers as warranted.
• Examine claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.
• Review and conduct analysis of claims and medical records prior to payment.
• Research new healthcare‑related questions as necessary to aid in investigations.
• Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommend possible interventions for loss control and risk avoidance based on the outcome of the investigation.

• Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA) and minimum of 4 years related experience, including minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.
• Fraud and Abuse experienced Nurse with a CPC are highly desired.

• For candidates working in person or virtually in the below location(s), the salary
  * range for this specific position is $65,968 to $124,992.
• Locations:
  California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Washington State.

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
  
  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 Company’s sole discretion, consistent with the law.

Job Level: Non‑Management Exempt
Job Shift: 1st Shift (United States of America)

Elevance Health is a health company dedicated to improving lives and communities — and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of…