Clinical Fraud Investigator II

Elevance Health

. Identify issues and/or entities that may pose potential risk associated with fraud and abuse .

Posted 10/7/2026full-timeUnited StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Fraud and Abuse Investigation, with strong analytical and critical-thinking skills to evaluate claims and medical records for compliance. Proficient in collaborating with internal teams to recommend effective interventions for risk avoidance and loss control.

Highest-signal resume keywords

Clinical Fraud And Abuse InvestigationCertified Professional Coder (AAPC Or AHIMA)Analytical SkillsCritical-Thinking SkillsClaims Compliance Review

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisClinical EvaluationInvestigative TechniquesClaims ExaminationRisk Assessment

Soft Skills

CollaborationProblem-Solving

Certifications & Qualifications

Associate Degree In NursingCertified Professional Coder (AAPC Or AHIMA)

Industry Keywords

Fraud PreventionAbuse ControlHealthcare ComplianceMedical Records ReviewLoss Control

About the role

Key responsibilities & impact

Identify issues and/or entities that may pose potential risk associated with fraud and abuse
Perform comprehensive analysis and clinical evaluation of collected data
Perform in-depth investigations on identified providers as warranted
Examine claims for compliance with relevant billing and processing guidelines
Identify opportunities for fraud and abuse prevention and control
Review and conduct retrospective analysis of claims and medical records prior to payment
Research new healthcare-related questions to aid investigations
Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern
Recommend interventions for loss control and risk avoidance based on investigation outcomes

Requirements

What you’ll need

Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA)
Minimum of 4 years related experience
Minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area
Any combination of education and experience providing an equivalent background
Registered Nurse preferred
Certified Professional Coder (AAPC or AHIMA) preferred
Investigations background
Applied analytical and critical-thinking skills
Candidates must reside within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
Position is not eligible for current or future VISA sponsorship
Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short-term disability benefits
Long-term disability benefits
401(k) + match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Hybrid work arrangement with virtual-work flexibility