Lead SIU Investigator

Centene Corporation•Remote-MO, NV

6d•$70,100 - $126,200•Remote

About The Position

Centene is seeking a Lead SIU Investigator to join their team. This role is responsible for acting as a subject matter expert in Special Investigations Unit (SIU) investigations, providing guidance to staff, and managing a caseload of moderate to high complexity. The investigator will also assist management with monitoring team caseloads, reporting on metrics, identifying training needs, and developing training materials. The position requires evaluating allegations against federal and state regulations, CMS guidelines, and internal policies, conducting and documenting interviews, and preparing clear and concise investigative plans and reports. The Lead SIU Investigator will consult with management and legal counsel, identify risks, recommend remedial actions, and ensure their implementation. They will also identify trends, generate proactive leads, analyze data for fraudulent activity, and communicate with business areas, regulators, and law enforcement. The role involves preparing cases for referral, building relationships with associates and regulators, testifying in legal matters, and participating in special projects. The position is remote and located anywhere within the continental US.

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.
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.

Nice To Haves

Master's Degree preferred.
Knowledge and understanding of managed care claims processing systems and medical claims coding preferred.
Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or other industry related certification preferred.

Responsibilities

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.
Participates in and lead special projects as needed.
Performs other duties as assigned.
Complies with all policies and standards.