Pharmacy Investigator Senior

Anticipated End Date:

2026-06-13

Position Title:

Pharmacy Investigator Senior

Job Description:

Pharmacy Investigator Senior

Location(s): 21215 Burbank Blvd, Woodland Hills, CA, 3080 Bristol St, Costa Mesa, CA and 2121 N. California Blvd, Walnut Creek, CA

Hybrid: 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.

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.

The Pharmacy Investigator Senior is responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims.

How you will make an impact:

• Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims. 

• Responsible for independently identifying and developing enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state. 

• May interface internally with Senior level management and legal department throughout investigative process.

• May assist in training of internal and external entities.

• Assists in the development of policy and/or procedures to prevent loss of company assets.

• May be called upon to represent the Company in court proceedings regarding research findings.

• Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. 

• 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. 

Minimum Qualifications:

• Requires a BA/BS and minimum of 5 years related experience in healthcare insurance and healthcare insurance investigation, law enforcement; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or Law Enforcement. 

• Pharmacy claims, records and investigations, experience.

• Pharmacy technician license and/or experience.

• Formulary, clinical rules, pharmacy claims analysis, and/or prior authorization experience for a pharmacy benefit manager or health plan.

• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation.

• Proficiency with Microsoft Office products, most notably expertise in Excel for reporting, Word, PowerPoint, Teams, and Outlook.

• One year or more Excel experience working with large data files and other general reporting tools.

• Experience with background research, data Mining and data analysis.

• Ability to communicate information clearly and concisely, both orally and in writing, in a professional and legal environment.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $90,160 to $141,120

 

Location(s): Woodland Hills, CA; Costa Mesa, CA; Walnut Creek, CA

 

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 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 remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.