SIU Investigator

Centene Corporation; New York (NY); On-site; USD 56,200 - 101,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Job summary

A leading health organization seeks an investigator for healthcare fraud allegations. Responsibilities include conducting investigations, analyzing claims data, and preparing reports. A bachelor's degree and 1+ years in medical claim analysis are essential. Preferred candidates will have a minimum of 5 years in fraud investigations. This is a remote role with a strong preference for residents of New York. The position offers competitive pay and comprehensive benefits.

Qualifications

• Bachelor's degree is required, with relevant experience in claim investigation.
• 1+ years of experience in medical claims audit or fraud investigation.
• Preferred: 5+ years in healthcare fraud investigations.

Responsibilities

• Conduct investigations of potential waste, abuse, and fraud.
• Document activity on each case and refer issues appropriately.
• Develop new queries to detect potential waste and fraud.

Skills

Medical claim investigation

Data mining and analysis

Fraud investigation

Education

Bachelor’s Degree in Business, Criminal Justice, Healthcare, or related field

Job description

Overview

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

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.

Responsibilities

• 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 in Business, Criminal Justice, Healthcare, related field or equivalent experience. 1+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience.

Preferred qualifications

a minimum of 5+ years in healthcare field working in fraud, waste and abuse investigations and audits, or 5+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or 7+ years of professional investigation experience involving economic or insurance related matters.

Please note: this is a remote role, however, candidates residing in the state of New York are highly preferred.

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