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Anthem, Inc. Clinical Fraud Investigator I in Hingham, Massachusetts

Description

SHIFT: Day Job

SCHEDULE: Full-time

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 care companies and a Fortune Top 50 Company.

The Clinical Fraud Investigator is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

Location: Work From Home, Open to locations in the US

Responsibilities:

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.

Qualifications

Requirements:

  • Requires an associate Degree in Nursing

  • Current certification as a Certified Professional Coder (AAPC or AHIMA),

  • 3 years related experience; or any combination of education and experience, which would provide an equivalent background.

    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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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: PS52291

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