Anthem, Inc Clinical Fraud Investigator II or Senior-PS16390 in Columbia, South Carolina

Clinical Fraud Investigator II or Senior-PS16390

Location: United States

Field: Fraud

Requisition #: PS16390

Post Date: Dec 27, 2018

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 benefits companies and a Fortune Top 50 Company.

This position may be located at any Anthem location or be remote.

We will hire either a Clinical Fraud Investigator II or Senior dependent on years of experience.

Responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. 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. 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. Trains new associates. Develops, designs and implements new or revised methods to improve the CIU operations.

Requires an associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA), 4-5 years related experience with 2 prior years experience in a Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background. RN is preferred; CPC is preferred.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at

An Equal Opportunity Employer/Disability/Veteran