Lead SIU Investigator

🔥 50 minutes ago

🌵 Arizona, Colorado, +3 more states – Remote

🌵 Arizona – Remote ⛰️ Colorado – Remote 🥔 Idaho – Remote 🏰 Missouri – Remote ☕ Washington – Remote

💵 $70.1k - $126.2k / year

⏰ Full Time

🟠 Senior

✨ Investigator

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Acts as a subject matter expert in the field of Special Investigations Unit (SIU) investigations • Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters • Assists manager on monitoring team caseload and report on metrics • Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse related matters • Assists manager on monitoring team caseload and report on metrics • Identifies training needs and develop training aids and step actions • Provides training and mentoring to team on casework and other SIU activities • Evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated • Conducts and documents interviews investigatory purposes • Reviews investigative interviews prepared by junior investigators • Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution • Thoroughly documents actions, organizes, and reviews case files • Consults with management, in-house counsel, and/or senior leadership to resolve difficult or complex issues • Identifies risks and recommends and communicates remedial actions to mitigate future potential risks • Performs follow up to ensure remedial and disciplinary measures are implemented appropriately and timely • Prepares clear and concise investigative plans and reports • Provides support and guidance to junior investigative staff • Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity • Attends, actively participates in, and/or leads meetings with various business area managers • Communicates directly with Federal or State regulators • Prepares cases for referral to management, government agencies, and law enforcement • Develops and maintains strong working relationships with associates and regulators • Testifies in criminal and civil matters • Participates in and lead special projects as needed • Performs other duties as assigned • Complies with all policies and standards

🎯 Requirements

• Bachelor's Degree in related field; or Associate's degree with 6 years related experience; or High School Diploma/GED with 7 years related experience • 5+ years Healthcare fraud-related investigations with audit and risk analysis required • 1+ years Managed care or working with health insurance company required • In-depth knowledge of government programs, the managed care industry, Medicare, Medicaid laws and requirements, federal, state, civil and criminal statutes required • Reading, analyzing and interpreting State and Federal laws, rules and regulations • Knowledge of community, state and federal laws and resources required • Knowledge and understanding of managed care claims processing systems and medical claims coding preferred

🏖️ Benefits

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work with remote, hybrid, field or office work schedules