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Centene Corporation
Special Investigation Unit InvestigatorCentene Corporation • Remote, Connecticut, United States
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Special Investigation Unit Investigator

Special Investigation Unit Investigator

Centene Corporation • Remote, Connecticut, United States
17 days ago
Job type
  • Full-time
  • Remote
Job description

Job Description:

  • Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources
  • Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes
  • Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation for potential fraud, waste, abuse, overpayments, or compliance concerns
  • Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties
  • Collaborate with business partners, compliance, legal, provider and payment integrity teams, and external agencies
  • Support corrective actions, recoveries, audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives
  • Monitor emerging fraud schemes, billing irregularities, and healthcare program risks and recommend appropriate actions
  • Support case progression through onsite audits, visits, drive-by activities, and interviews
  • Comply with all policies and standards and perform other duties as assigned

Requirements:

  • Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience
  • 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
  • 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
  • Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development preferred
  • AHFI, CFE, CPC, CPMA, or other related investigative, auditing, or compliance certification preferred
  • Compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures

Benefits:

  • Health insurance
  • 401K
  • Stock purchase plans
  • Tuition reimbursement
  • Paid time off plus holidays
  • Flexible approach to work with remote, hybrid, field or office work schedules
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Special Investigation Unit Investigator • Remote, Connecticut, United States

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