Anticipated End Date: 2026-01-02 Position Title: Pharmacy Investigator Lead Job
Description: Location: Atlanta GA, Richmond VA, Costa Mesa CA, Indianapolis IN
Hours: Standard Working hours Travel: This role requires associates to be
in-office 1 - 2 days per week, fostering collaboration and connectivity, while
providing flexibility to support productivity and work-life balance. This
approach combines structured office engagement with the autonomy of virtual
work, promoting a dynamic and adaptable workplace. Alternate locations may be
considered if candidates reside within a commuting distance from an office.
Please note that 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. Position Overview: Responsible for providing leadership and guidance to the
Special Investigations Unit Pharmacy team in investigating, collecting,
researching and analyzing billing data in order to detect fraudulent, abusive or
wasteful activities/practices. Provides comprehensive sound judgment in the
application of various investigative methodologies to team members and is able
to effectively evaluate and recommend focused investigative activities involving
market trends indicating Fraud, Waste and Abuse within the healthcare industry.
How You Will Make an Impact: Assisting the team manager with the administration
and operational activities occurring within the Special Investigations Unit for
pharmacy Investigations; coordinating and conducting case reviews for quality
assurance, investigative sufficiency, and case data management; and direction of
day-to-day operations as assigned by management Through use of appropriate
system tools, provides training for and conducts analysis of data to detect
fraudulent, abusive or wasteful payments to providers and subscribers Prepares
statistical/financial analyses and reports to document findings and maintains
up-to-date case files for management review Prepares final report and
notification of findings letter suitable for distribution to providers and legal
counsel Creates and presents settlement offers for provider issues for review
and approval by management and/or legal Communicates orally and in writing with
all customers, internal and external, regarding findings Assists management and
provides recommendation in support of the development of policy and/or
procedures to prevent loss of company assets Prepares and delivers training to
internal and external entities Develops and maintains a high degree of rapport
and cooperation with the Federal, State and local law enforcement and regulatory
agencies which can assist in investigative efforts Represents the Company in
court proceedings regarding research findings Provides guidance to investigators
and other SIU staff in the development of criminal and recovery cases Leads SIU
projects or initiatives Required Qualifications: Requires a BA/BS and minimum of
8 years related experience in healthcare insurance and healthcare insurance
investigation; or any combination of education and experience, which would
provide an equivalent background. Preferred Qualifications: PharmD or CPhT
strongly preferred Knowledge and experience working with Pharmacy Benefit
Managers and Pharmacy programs strongly 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 For candidates working
in person or virtually in the below location(s), the salary range for this
specific position is $87,280 to $150,558 Location: California In addition to
your salary, Elevance Health offers benefits such as, a comprehensive benefits
package, incentive and recognition programs, equity stock purchase and 401k
contribution (all benefits are subject to eligibility requirements). The salary
offered for this specific position is based on a number of legitimate,
non-discriminatory factors set by the Company. The Company is fully committed to
ensuring equal pay opportunities for equal work regardless of gender, race, or
any other category protected by federal, state, and local pay equity laws. 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 Job Level:
Non-Management Exempt Workshift: 1st Shift (United States of America) Job
Family: FRD > Investigation Please be advised that Elevance Health only accepts
resumes for compensation from agencies that have a signed agreement with
Elevance Health. Any unsolicited resumes, including those submitted to hiring
managers, are deemed to be the property of Elevance Health. Who We Are 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. How We Work 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
our culture. They are how we achieve our strategy, power our business outcomes
and drive our shared success - for our consumers, our associates, our
communities and our business. 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. Elevance Health operates in a Hybrid Workforce
Strategy. Unless specified as primarily virtual by the hiring manager,
associates are required to work at an Elevance Health location at least once per
week, and potentially several times per week. Specific requirements and
expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance
Health. We require all new candidates in certain patient/member-facing roles to
become vaccinated against COVID-19 and Influenza. If you are not vaccinated,
your offer will be rescinded unless you provide an acceptable explanation.
Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer, and all qualified
applicants will receive consideration for employment without regard to age,
citizenship status, color, creed, disability, ethnicity, genetic information,
gender (including gender identity and gender expression), marital status,
national origin, race, religion, sex, sexual orientation, veteran status or any
other status or condition protected by applicable federal, state, or local laws.
Applicants who require accommodation to participate in the job application
process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for
employment in accordance with all federal, state, and local laws, including, but
not limited to, the Los Angeles County Fair Chance Ordinance and the California
Fair Chance Act. Elevance Health is a health company dedicated to improving
lives and communities – and making healthcare simpler. Previously known as
Anthem, Inc., we have evolved into a company focused on whole health and updated
our name to better reflect the direction the company is heading. Join our Talent
Community and stay connected with company news, information, and future job
opportunities. Fueled by our bold purpose to improve the health of humanity, we
are transforming from a traditional health benefits organization into a lifetime
trusted health partner. Our nearly 100,000 associates serve approximately 100M+
people, at every stage of health. We address a full range of needs with an
integrated whole health approach, powered by industry-leading capabilities and a
digital platform for health. Please visit the Contract Worker Community Page.
Elevance Health is an Equal Opportunity Employer/Disability/Veterans.
