Investigation Quality Audit Analyst

Centene Corporation

About The Position

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 Purpose: Ensures the integrity, quality, and compliance of healthcare investigations through audits, process improvements, and collaboration with investigative teams. Combines analytical review, training, reporting, and some policy development to support organizational goals and regulatory standards. Conduct regular audits of Special Investigation Unit (SIU) and Compliance Investigation Unit (CIU) investigative case documentation and notes to ensure compliance with internal policies and procedures as well as demonstration of critical thinking and industry standards around healthcare fraud investigations. Assist in identification of trends, discrepancies, or potential areas of risk, providing actionable items to leadership. Develop and maintain audit tools, scorecards, and tracking systems to ensure consistent and objective reviews. Collaborate with Investigative teams and leadership to address audit findings and implement remediation plans. Support development and updates for investigative policies and procedures along with training materials based on audit results and findings. Monitor implementation of process changes to ensure sustained compliance and improved quality outcomes. Provide feedback and support to investigative leadership on documentation requirements, best practices, and quality standards. Participate in training sessions to support ongoing staff education related to compliance and investigation excellence. Prepare audit reports and present findings to management with clear insights and recommendations. Track performance metrics, compliance trends, and improvement initiatives to measure program effectiveness. Work closely with leadership to ensure alignment of audit activities with organizational goals. Participate in internal and external audits as needed. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Bachelor's Degree Business, Criminal Justice, Healthcare, related field or equivalent experience required.
3+ years experience in medical claim investigation, medical claim audit, medical claim analysis, SIU functions or healthcare fraud investigation or 2+ years with a relevant certification (CFE, AHFI,CIA,CHC,CPC or CPMA) required.

Nice To Haves

Certified Fraud Examiner (CFE)
Healthcare Fraud Investigator Certification (HFIC)
Certified Internal Auditor (CIA)
Accredited Healthcare Fraud Investigator (AHFI)
Certified in Healthcare Compliance (CHC)

Responsibilities

Conduct regular audits of Special Investigation Unit (SIU) and Compliance Investigation Unit (CIU) investigative case documentation and notes to ensure compliance with internal policies and procedures as well as demonstration of critical thinking and industry standards around healthcare fraud investigations.
Assist in identification of trends, discrepancies, or potential areas of risk, providing actionable items to leadership.
Develop and maintain audit tools, scorecards, and tracking systems to ensure consistent and objective reviews.
Collaborate with Investigative teams and leadership to address audit findings and implement remediation plans.
Support development and updates for investigative policies and procedures along with training materials based on audit results and findings.
Monitor implementation of process changes to ensure sustained compliance and improved quality outcomes.
Provide feedback and support to investigative leadership on documentation requirements, best practices, and quality standards.
Participate in training sessions to support ongoing staff education related to compliance and investigation excellence.
Prepare audit reports and present findings to management with clear insights and recommendations.
Track performance metrics, compliance trends, and improvement initiatives to measure program effectiveness.
Work closely with leadership to ensure alignment of audit activities with organizational goals.
Participate in internal and external audits as needed.
Performs other duties as assigned.
Complies with all policies and standards.