Senior Pharmacy SIU Investigator

Job not on LinkedIn

🔥 0 minutes ago

🐊 Florida, Ohio, +1 more states – Remote

🐊 Florida – Remote 🏈 Ohio – Remote 🏰 Missouri – Remote

💵 $70.1k - $126.2k / year

⏰ Full Time

🟠 Senior

💊 Pharmacist

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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

• Independently lead complex fraud, waste, and abuse investigations involving providers, members, pharmacies, vendors, and other entities • Use referrals, claims data, medical records, interviews, analytics, and other investigative resources to develop cases • Analyze claims, billing patterns, medical records, provider documentation, financial information, and other evidence • Develop investigative strategies, establish case direction, and manage investigations through resolution • Prepare investigative reports, referrals, case summaries, presentations, and supporting documentation • Provide subject matter guidance to investigative staff on techniques, case development, documentation, evidence, and regulations • Collaborate with Compliance, Legal, Payment Integrity, Provider Relations, government agencies, and law enforcement partners • Identify emerging fraud schemes, billing irregularities, control gaps, and program integrity risks • Recommend enhancements to investigative processes, monitoring activities, and analytical approaches • Support audits, overpayment identification and recovery, regulatory responses, special projects, and enterprise initiatives • Ensure investigations meet quality, timeliness, documentation, service-level, and regulatory requirements • Assist with training, knowledge sharing, and continuous improvement initiatives • Support case progression through onsite audits, visits, drive-by activities, and member, provider, and witness interviews • Perform other duties as assigned and comply with policies and standards

🎯 Requirements

• Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent experience required • 4+ years conducting fraud, waste, and abuse investigations, healthcare fraud investigations, claims audits, payment integrity reviews, healthcare compliance investigations, law enforcement investigations, or related investigative work • Experience leading complex investigations involving multiple data sources, extensive analysis, and internal and external stakeholder coordination • Experience preparing investigative reports, referrals, presentations, and supporting documentation for leadership, regulatory agencies, and law enforcement entities • Experience interpreting and applying federal and state healthcare regulations, including Medicaid, Medicare, and other government-sponsored healthcare programs preferred • Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or related investigative, auditing, or compliance certification preferred • Additional qualifications may be required to satisfy applicable federal, state, regulatory, contractual, or program-specific requirements

🏖️ 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 • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity