Clinical Fraud Investigator II

Elevance Health

Clinical Fraud Investigator II at Elevance Health assessing healthcare claims for fraud and compliance issues. Collaborating with internal teams and conducting retrospective analysis of claims and medical records.

Posted 7/13/2026full-timeAtlanta • Florida • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical evaluation and fraud investigation within healthcare, utilizing advanced analytical skills and compliance knowledge to ensure adherence to billing guidelines and risk management strategies.

Highest-signal resume keywords

Clinical Fraud InvestigationData AnalysisAdvanced Excel SkillsCertified Professional CoderClaims Compliance

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical EvaluationData AnalysisClaims ExaminationRetrospective AnalysisInvestigative Research

Soft Skills

CollaborationCommunication

Tools & Technologies

Excel

Certifications & Qualifications

Associate Degree in NursingCertified Professional Coder (AAPC or AHIMA)

Industry Keywords

Healthcare ComplianceBilling GuidelinesRisk ManagementLoss ControlSpecial Investigation Unit

About the role

Key responsibilities & impact

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
Review and conducts retrospective 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

Requirements

What you’ll need

Requires an 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
Advanced Excel skills, including Pivot Tables

Benefits

Comp & perks

merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical, dental, vision
short and long term disability benefits
401(k) +match
stock purchase plan
life insurance
wellness programs
financial education resources