Special Investigation Unit 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. 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.
Education/Experience 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 Pay Range $56,200.00 - $101,000.00 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