SIU Investigator

Centene Corporation

5d•Remote

About The Position

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. Please note: This is a remote position, however, candidates who reside within the state of New York are highly preferred. Position Purpose: 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 Business, Criminal Justice, Healthcare, or related field, or equivalent experience required.
Minimum of five (5) years in healthcare field working in fraud, waste and abuse investigations and audits, (or) five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, (or) seven years of professional investigation experience involving economic or insurance related matters.

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.