Senior SIU Investigator

Summary

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.Position PurposeInvestigate allegations of healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.ResponsibilitiesAssist in monitoring business processes and systems to assure integrity and compliance in billing and claims paymentInvestigate possible waste, abuse and fraud leads and document activity on each lead and refer issues to the appropriate partyDevelop internal reports to identify potential waste, abuse and fraudPerform data mining and analysis to detect aberrancies and outliers in claimsServe as point of contact for corporate and field inquiries regarding waste, abuse and fraudReview post-payment cases with appropriate parties to obtain refundProvide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutionsPrepare summary and detailed reports on investigative findings for referral to Federal and State agenciesArrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigationsEducation / ExperienceBachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience. Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.Licenses / CertificationsCertified Professional Coder preferred.Pay Range$70,100.00 - $126,200.00 per yearBenefitsCentene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.EEO StatementCentene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.AdditionalQualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.#J-18808-Ljbffr

Job Description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.Position PurposeInvestigate allegations of healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.ResponsibilitiesAssist in monitoring business processes and systems to assure integrity and compliance in billing and claims paymentInvestigate possible waste, abuse and fraud leads and document activity on each lead and refer issues to the appropriate partyDevelop internal reports to identify potential waste, abuse and fraudPerform data mining and analysis to detect aberrancies and outliers in claimsServe as point of contact for corporate and field inquiries regarding waste, abuse and fraudReview post-payment cases with appropriate parties to obtain refundProvide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutionsPrepare summary and detailed reports on investigative findings for referral to Federal and State agenciesArrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigationsEducation / ExperienceBachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience. Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.Licenses / CertificationsCertified Professional Coder preferred.Pay Range$70,100.00 - $126,200.00 per yearBenefitsCentene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.EEO StatementCentene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.AdditionalQualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.#J-18808-Ljbffr