Clinical Fraud Director 64420
WellPoint - United States

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WellPoint is one of the nations leading health benefits companies and a Fortune Top 50 company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to simplify the connection between health, care, and value for our customers.

Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Clinical Fraud Director

Any WellPoint Site

Responsible for leading the Wellpoint Special Investigations Investiclaim Clinical Triage team. Provide specialized assistance to the Special Investigations Unit including conducting medical record reviews, peer discussions, on site audits and investigative strategy development and management of enterprise wide specialty medical management initiatives to enhance successes of recovery prosecution and provider behavioral changes.. Primary duties include: Development of triage processes and job aids, support for offshore triage teams and onshore investigations, performing record requests and chart reviews, support InvestiClaim configuration, reporting and queue management. Provides day-to-day guidance, support, and leadership for clinical and quality activities associated with the InvestiClaim project. Provides specialized assistance to the networks in administrative, clinical and procedural knowledge of area. management of enterprise wide specialty medical management initiatives.

Job Qualifications

Requires a BA/BS with a specialized advanced degree/coding and nursing certification preferred; 7+ years clinical/fraud experience, or any combination of education and experience, which would provide an equivalent background.

WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2012 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers . EOE

Once an offer is accepted, all external applicants are subject to a background investigation
and if appropriate, drug testing. Offers of employment shall be contingent upon
passing both the background investigation and drug testing (if required).

  • Current WellPoint associates: All referrals must be submitted through the formal
associate referral process on WorkNet. Official guidelines for the associate referral
program can be found in My HR.

  • WARNING: Please beware of phishing scams. Our company will never ask
you for bank account information when you are applying for a job.

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About this company
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WellPoint, Inc. (WellPoint) is a health benefits company serving 35 million medical members, as of December 31, 2008. The Company is an...