Lead SIU Investigator

You could be the one who changes everything for our 28 million members. 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: Candidate must reside within the state of Kentucky Position Purpose: Position acts as a subject matter expert for the Contractor’s Program Integrity unit to reduce Fraud, Waste and Abuse of Medicaid services within Kentucky. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics.

• Serve as the single point of contact with the Department
• Facilitate timely response to Department requests for information
• Serve as a lead for the Kentucky market
• Manage and coordinate cases being investigated by the SIU
• Maintain all vendor cases
• Assist with conducting complex investigations, including on-site investigations, review, complete and submit FWA referrals to the state as needed
• Maintain and approve all reports submitted to the state
• Monitor state contract and regulatory changes that may arise
• Works quickly, with great attention to detail, while managing competing priorities.
• Logs, tracks, resolves and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and WellCare Corporate guidelines in which special care is required to protect and enhance WellCare’s reputation.
• Works cross-functionally in preparation of effective communications with stakeholders on social channels and provides content to appropriately respond to social media posts regarding provider inquires.
• Tracks & trends issues that result in AHCA complaints for purposes of developing preventive measures
• Escalates customer service questions to other appropriate internal teams as needed.
• Supports the provider escalation project team to resolve claims and payment issues.
• Identifies root-cause issues to ensure enterprise solutions and communicate findings as needed.
• Shares case studies and best practices throughout the enterprise.
• Contributes to the creation of documentation such as SOP’s, FAQ’s, and resources to be used by internal customer service agents.
• Researches escalated issues and takes appropriate action to resolve them within established service level agreements, WellCare best practice and quality standards.
• Applies a comprehensive knowledge of claims processing, provider customer service and payment knowledge to escalated provider inquiries.

Education/Experience: Bachelor’s degree in related field or Associate’s degree with 6 years of applicable experience, or a High School/GED with 7 years of applicable experience may substitute for the Bachelors Degree . 5+ years of management experience Investigations and healthcare fraud-related investigations with audit and risk analysis. 1+ year of experience in managed care or health insurance company. Candidate Skills: In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes. Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources. Ability to work in a fast paced environment with changing priorities. Intermediate Excel, Outlook, PowerPoint, Word, Xcelys, SalesForce, and Microsoft Access. Knowledge and understanding of managed care claims processing systems and medical claims coding preferred Licenses and Certifications: A license in one of the following is required: Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE). Other Pharmacy Investigator - Certified Pharmacy Technician. Pay Range: $68,700.00 - $123,700.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply tot his job Apply To this Job