Special Investigation Unit Investigator

Centene Corporation•Remote-NY, CT

5d•$56,200 - $101,000•Hybrid

About The Position

Conduct 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. Document investigative activities, prepare reports and referrals, collaborate with internal and external stakeholders, and support program integrity efforts while ensuring compliance with applicable laws, regulations, contractual obligations, and organizational standards. Conducts fraud, waste, and abuse (FWA) investigations utilizing referrals, claims data, medical records, interviews, data analytics, and other investigative resources to identify potential misconduct and support case resolution. Analyzes, documents, and maintains investigative activities, findings, recommendations, and outcomes in accordance with established procedures, regulatory requirements, and service standards. Reviews claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns. Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate. Collaborates with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigative activities, support corrective actions, recoveries, and case resolution efforts. Supports audits, overpayment identification and recovery efforts, regulatory responses, special projects, and other program integrity initiatives. Maintains compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures. Monitors for emerging fraud schemes, billing irregularities, and trends that may present risks to healthcare programs and recommend appropriate actions for further review. Supports investigative case progression through onsite audits, visits, drive-by and additional investigative activities such as a member, provider, witness interviews, etc. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Bachelor's Degree Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience (or) 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
Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development, preferred.
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.

Nice To Haves

Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE)[MF1.1], Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or other related investigative, auditing, or compliance certification.

Responsibilities

Conducts fraud, waste, and abuse (FWA) investigations utilizing referrals, claims data, medical records, interviews, data analytics, and other investigative resources to identify potential misconduct and support case resolution.
Analyzes, documents, and maintains investigative activities, findings, recommendations, and outcomes in accordance with established procedures, regulatory requirements, and service standards.
Reviews claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns.
Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate.
Collaborates with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigative activities, support corrective actions, recoveries, and case resolution efforts.
Supports audits, overpayment identification and recovery efforts, regulatory responses, special projects, and other program integrity initiatives.
Maintains compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures.
Monitors for emerging fraud schemes, billing irregularities, and trends that may present risks to healthcare programs and recommend appropriate actions for further review.
Supports investigative case progression through onsite audits, visits, drive-by and additional investigative activities such as a member, provider, witness interviews, etc.
Performs other duties as assigned.
Complies with all policies and standards.