Senior SIU Investigator

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

💵 $70.1k - $126.2k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Independently lead complex fraud, waste, and abuse investigations involving providers, members, pharmacies, vendors, and other entities • 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, and supporting documentation • Provide subject matter guidance to investigative staff on techniques, 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 • 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-bys, and 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 coordination with internal and external stakeholders • 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 • Must be authorized to work in the U.S. without employment-based visa sponsorship now or in the future • Additional qualifications may be required to satisfy applicable federal, state, regulatory, contractual, or program-specific requirements • AHFI, CFE, CPC, CPMA, or other related investigative, auditing, or compliance certification preferred

🏖️ Benefits

• Health insurance • 401K plan • Stock purchase plan • Tuition reimbursement • Paid time off • Paid holidays • Flexible approach to remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation