Special Investigation Unit Investigator

Centene Corporation

1d•Hybrid

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. 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
1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required
For New York Plan only: 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; (and) An Associates or Bachelor's degree in criminal justice or a related field; (or) employment as an investigator in the MMCO's SIU on or before the effective date of this SubPart. required
For Kentucky plan only: Minimum of three (3) years Medicaid fraud, waste and abuse investigatory experience located in Kentucky dedicated 100% to the Kentucky Medicaid Program. required
For Ohio plan only: A minimum of 2 years in a health care field working on fraud, waste, and abuse investigations and audits; a Bachelor's degree, or an Associate's degree with an additional 2 years working on health care fraud, waste, and abuse investigations and audits. The ability to understand and analyze health care claims and coding. required
For Nebraska Plan only: A Bachelor's Degree; or an Associate's degree plus a minimum of 2 years' experience as a licensed health care provider or auditor; or a minimum of 4 years' experience as a certified coder or billing specialist; or a minimum of 5 years law enforcement, health care oversight, compliance, or auditing experience. required
New Jersey Plan only: Bachelor's degree; or an Associate's degree plus 2 years' experience with health care related employment; or 4 years' experience with health care related employment; or 5 years' of law enforcement experience. required
North Carolina Plan only: Associate's or Bachelor's degree in criminal justice or related field; or 3 years' relevant experience. 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.