SIU Investigator

Centene Corporation•Remote-OH, MI

3d•$56,200 - $101,000•Remote

About The Position

Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Conduct investigations of potential waste, abuse, and fraud. Document activity on each case and refer issues to the appropriate party. Perform data mining and analysis to detect aberrancies and outliers in claims. Develop new queries and reports to detect potential waste, abuse, and fraud. Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions. Assist with complex allegations of healthcare fraud. Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies. Complete various special projects and audits. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Bachelor's degree, or an Associate's degree with an additional 2 years working on health care fraud, waste, and abuse investigations and audits in lieu of a Bachelors is required.
A minimum of 2 years in a health care field working on fraud, waste, and abuse investigations and audits required.
The ability to understand and analyze health care claims and coding required.

Responsibilities

Investigate allegations of potential healthcare fraud and abuse activity.
Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.
Conduct investigations of potential waste, abuse, and fraud.
Document activity on each case and refer issues to the appropriate party.
Perform data mining and analysis to detect aberrancies and outliers in claims.
Develop new queries and reports to detect potential waste, abuse, and fraud.
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions.
Assist with complex allegations of healthcare fraud.
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies.
Complete various special projects and audits.
Performs other duties as assigned.
Complies with all policies and standards.