Lead SIU Investigator

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: Position acts as a subject matter expert in the field of Compliance and/or Special Investigations Unit (SIU) investigations. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics. Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse related matters Assists manager on monitoring team caseload and report on metrics Identifies training needs and develop training aids and step actions Provides training and mentoring to team on casework and other SIU activities Evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated Conducts and documents interviews investigatory purposes Reviews investigative interviews prepared by junior investigators. Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution Thoroughly documents actions, organizes, and reviews case files. Consults with management, in-house counsel, and/or senior leadership to resolve difficult or complex issues Identifies risks and recommends and communicates remedial actions to mitigate future potential risks Performs follow up to ensure remedial and disciplinary measures are implemented appropriately and timely Prepares clear and concise investigative plans and reports Provides support and guidance to junior investigative staff Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity Attends, actively participates in, and/or leads meetings with various business area managers Communicates directly with Federal or State regulators Prepares cases for referral to management, government agencies, and law enforcement Develops and maintains strong working relationships with associates and regulators Testifies in criminal and civil matters Supports the development and maintenance of Corporate Compliance policies and procedures and workflows Participates in and lead special projects as needed Perform other duties as assigned Complies with all policies and standards

Requirements

Bachelor's Degree in related field; or Associate's degree with 6 years related experience; or High School Diploma/GED with 7 years related experience required
5+ years Healthcare fraud-related investigations with audit and risk analysis required
1+ years Managed care or working with health insurance company required
In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes required
Reading, analyzing and interpreting State and Federal laws, rules and regulations.
Knowledge of community, state and federal laws and resources required
Knowledge and understanding of managed care claims processing systems and medical claims coding preferred

Nice To Haves

Master's Degree preferred
Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Pharmacy Technician, or other industry related certification preferred

Responsibilities

Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity.
Assists manager on monitoring team caseload and report on metrics.
Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse related matters
Assists manager on monitoring team caseload and report on metrics
Identifies training needs and develop training aids and step actions
Provides training and mentoring to team on casework and other SIU activities
Evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated
Conducts and documents interviews investigatory purposes
Reviews investigative interviews prepared by junior investigators.
Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution
Thoroughly documents actions, organizes, and reviews case files.
Consults with management, in-house counsel, and/or senior leadership to resolve difficult or complex issues
Identifies risks and recommends and communicates remedial actions to mitigate future potential risks
Performs follow up to ensure remedial and disciplinary measures are implemented appropriately and timely
Prepares clear and concise investigative plans and reports
Provides support and guidance to junior investigative staff
Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity
Attends, actively participates in, and/or leads meetings with various business area managers
Communicates directly with Federal or State regulators
Prepares cases for referral to management, government agencies, and law enforcement
Develops and maintains strong working relationships with associates and regulators
Testifies in criminal and civil matters
Supports the development and maintenance of Corporate Compliance policies and procedures and workflows
Participates in and lead special projects as needed
Perform other duties as assigned
Complies with all policies and standards