Special Investigation Unit Investigator

🔥 18 minutes ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟡 Mid-level

🟠 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

• Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources • Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes • Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation for potential fraud, waste, abuse, overpayments, or compliance concerns • Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties • Collaborate with business partners, compliance, legal, provider and payment integrity teams, and external agencies • Support corrective actions, recoveries, audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives • Monitor emerging fraud schemes, billing irregularities, and healthcare program risks and recommend appropriate actions • Support case progression through onsite audits, visits, drive-by activities, and interviews • Comply with all policies and standards and perform other duties as assigned

🎯 Requirements

• Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience • An Associates or Bachelor's degree in criminal justice or a related field; or employment as an investigator in the MMCO's SIU on or before the effective date of this SubPart • Minimum of five (5) years in healthcare field working in fraud, waste and abuse investigations and audits, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance related matters • Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development preferred • AHFI, CFE, CPC, CPMA, or other related investigative, auditing, or compliance certification preferred • Compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures

🏖️ Benefits

• Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules