SIU Investigator

Centene Corporation•Remote-TX, TX

22d•$56,200 - $101,000

About The Position

The SIU Investigator conducts fraud, waste, and abuse (FWA) investigations by reviewing referrals, claims data, medical records, provider information, and other relevant evidence to identify potential misconduct and support case resolution. The role documents investigative activities, prepares reports and referrals, collaborates with internal and external stakeholders, and supports program integrity efforts while ensuring compliance with applicable laws, regulations, contractual obligations, and organizational standards. The position also supports audits, overpayment identification and recovery, regulatory responses, special projects, and other program integrity initiatives. Investigative work may include onsite audits and visits, drive-bys, and interviews with members, providers, witnesses, and others. The investigator monitors emerging fraud schemes, billing irregularities, and trends, and recommends appropriate actions for further review. Other duties may be assigned, and the employee must comply with all policies and standards.

Requirements

Bachelor's degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent experience.
At least 2 years of experience in FWA investigations, healthcare investigations, claims audits, payment integrity, healthcare compliance, law enforcement investigations, or a related investigative field.

Nice To Haves

Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development.
Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or another related investigative, auditing, or compliance certification.

Responsibilities

Conduct FWA investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources.
Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes in accordance with established procedures, regulatory requirements, and service standards.
Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns.
Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate.
Collaborate with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigations and support corrective actions, recoveries, and case resolution.
Support audits, overpayment identification and recovery efforts, regulatory responses, special projects, and other program integrity initiatives.
Maintain compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures.
Monitor emerging fraud schemes, billing irregularities, and trends that may present risks to healthcare programs, and recommend appropriate actions for further review.
Support investigative case progression through onsite audits, visits, drive-bys, and investigative activities such as member, provider, and witness interviews.
Perform other duties as assigned.
Comply with all policies and standards.