Senior SIU Investigator

🔥 0 minutes ago

🦌 Connecticut, Florida, +3 more states – Remote

🦌 Connecticut – Remote 🐊 Florida – Remote 🗽 New York – Remote 🍂 Massachusetts – Remote 🔔 Pennsylvania – Remote

💵 $70.1k - $126.2k / year

⏰ Full Time

🟠 Senior

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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 • Use referrals, claims data, medical records, interviews, analytics, and other investigative resources to develop cases • Analyze complex 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 improvements to investigative processes, monitoring activities, and analytical approaches • Support audits, overpayment identification and recovery, regulatory responses, special projects, enterprise initiatives, and complex investigative matters • 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 required • 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 • Ability to interpret and apply federal and state healthcare regulations, including Medicaid, Medicare, and other government-sponsored healthcare programs preferred • Additional qualifications may be required for applicable federal, state, regulatory, contractual, or program-specific requirements • AHFI, CFE, CPC, CPMA, or another related investigative, auditing, or compliance certification preferred • Ability to conduct onsite audits, visits, drive-by activities, and interviews • Master's Degree preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • 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