Senior SIU Investigator

Centene Corporation; Illinois; Hybrid; USD 70,100 - 126,200; Full time

Benefits offered by this job

Health insurance

401K

Tuition reimbursement

Paid time off

Flexible work schedules

Job summary

A major healthcare organization is looking for an individual to investigate healthcare fraud and abuse within a dynamic role. You will be responsible for auditing claims, developing reports on fraud activity, and coordinating with various stakeholders, including regulatory agencies. A bachelor’s degree and at least 3 years of experience in healthcare investigations or audits are required. Additional benefits include competitive pay, flexible working schedules, and comprehensive health benefits.

Qualifications

• 3+ years of experience in medical claim investigations or fraud investigations.
• Experience with medical claim audits or analysis preferred.
• Knowledge of healthcare fraud and abuse regulations.

Responsibilities

• Investigate allegations of healthcare fraud.
• Assist in planning and executing special claims investigations.
• Monitor business processes for compliance in billing and claims.

Skills

Investigative skills

Data analysis

Knowledge of medical coding

Claims processing knowledge

Education

Bachelor’s Degree in Business or related field

Tools

Microsoft Applications

Job description

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 healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.

Responsibilities

• Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment
• Investigate possible waste, abuse and fraud leads and document activity on each lead and refer issues to the appropriate party
• Develop internal reports to identify potential waste, abuse and fraud
• Perform data mining and analysis to detect aberrancies and outliers in claims
• Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud
• Review post-payment cases with appropriate parties to obtain refund
• Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions
• Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies
• Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations

Education / Experience

Bachelor’s Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience. Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.

Licenses / Certifications

Certified Professional Coder preferred.

Pay Range

$70,100.00 - $126,200.00 per year

Benefits

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.

EEO Statement

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.

Additional

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.