Investigator Lead – Pharmacy

Elevance Health

. Provide leadership and guidance to the Special Investigations Unit team .

Posted 9/22/2026full-timeUnited StatesSenior💰 $87,280 - $157,104 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare insurance investigation, including data analysis and fraud detection, while providing leadership and training to team members. Proficient in preparing reports and communicating findings to various stakeholders, ensuring compliance with policies and procedures.

Highest-signal resume keywords

Healthcare Insurance InvestigationFraud Detection and AnalysisTeam Leadership and TrainingStatistical and Financial ReportingProfessional Certification (CFE, AHFI, CPC, Paralegal, RN, JD)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisBilling Data InvestigationQuality AssuranceCase Data ManagementStatistical AnalysisFinancial AnalysisReport PreparationNegotiation SkillsPharmacy InvestigationPolicy Recommendation

Soft Skills

Communication SkillsInterpersonal SkillsLeadership SkillsTraining and Development

Certifications & Qualifications

CFEAHFICPCParalegalRNJD

Industry Keywords

Special Investigations UnitFraudulent ActivitiesHealthcare InsuranceRegulatory AgenciesLegal CounselCase Files ManagementProvider IssuesCourt Proceedings

About the role

Key responsibilities & impact

Provide leadership and guidance to the Special Investigations Unit team
Investigate, collect, research, and analyze billing data to detect fraudulent, abusive, or wasteful activities and practices
Assist the team manager with Special Investigations Unit administration and operations
Coordinate and conduct pharmacy case reviews for quality assurance, investigative sufficiency, and case data management
Direct day-to-day operations as assigned by management
Train team members and analyze data using appropriate system tools to detect fraudulent, abusive, or wasteful payments
Prepare statistical and financial analyses and reports documenting findings
Maintain up-to-date case files for management review
Prepare final reports and notification-of-findings letters for providers and legal counsel
Create and present settlement offers for provider issues for management and/or legal approval
Communicate findings orally and in writing to internal and external customers
Recommend policies and procedures to prevent loss of company assets
Prepare and deliver training to internal and external entities
Develop and maintain relationships with federal, state, and local law enforcement and regulatory agencies
Represent the Company in court proceedings regarding research findings
Guide investigators and SIU staff in developing criminal and recovery cases
Lead SIU projects and initiatives

Requirements

What you’ll need

BA/BS required
Minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation
PharmD or CPhT strongly preferred
Pharmacy investigation experience preferred
Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job-related designation preferred
Knowledge of Plan policies and procedures in all facets of benefit programs management, with heavy emphasis in negotiation preferred
Candidates must be within a reasonable commuting distance from the posting locations unless an accommodation is granted as required by law
Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza

Benefits

Comp & perks

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
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) with match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Hybrid work flexibility
COVID-19 and Influenza vaccination requirements for certain patient/member-facing roles