SIU Investigator

Centene Corporation•Remote-TX, TX

5d•$56,200 - $101,000•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. This is a remote role with preference on candidates located in Texas. The purpose of this position is to investigate allegations of potential healthcare fraud and abuse activity. This role will assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. The investigator will conduct investigations of potential waste, abuse, and fraud, document activity on each case, and refer issues to the appropriate party. Responsibilities include performing data mining and analysis to detect aberrancies and outliers in claims, developing new queries and reports to detect potential waste, abuse, and fraud, and providing case updates on the progress of investigations. The role also involves coordinating with Health Plans on recommendations and further actions and/or resolutions, assisting with complex allegations of healthcare fraud, and preparing summary and/or detailed reports on investigative findings for referral to Federal and State agencies. The position also includes completing various special projects and audits and performing other duties as assigned, while complying with all policies and standards.

Requirements

Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required.
1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation 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.