SIU Investigator

Centene Corporation; North Carolina; Híbrido; USD 56 000 - 101 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Resumo da oferta

Centene Corporation seeks an Investigator to conduct fraud, waste, and abuse investigations across healthcare programs. You will review referrals, claims data, and medical records, document findings, and support case resolution while ensuring regulatory and contractual compliance.

Responsibilities include preparing reports, collaborating with compliance, legal, and external agencies, and supporting audits and recoveries. A Bachelor's degree and 2+ years in FWA or related fields are required.

Qualificações

• Bachelor's degree in Business, Criminal Justice, Healthcare Administration, Public Health, or related field; or equivalent experience.
• 2+ years in fraud, waste, and abuse investigations or related investigative field.
• Experience analyzing healthcare claims, medical records, or related documents to support investigations.

Responsabilidades

• Conduct FWA investigations using referrals, claims data, medical records, interviews, and analytics.
• Prepare investigative reports, case summaries, and referrals for internal and external stakeholders.
• Collaborate with compliance, legal, provider and payment integrity teams, and external agencies.

Conhecimentos

FWA investigations

Data analysis

Interviews/documentation

Formação académica

Bachelor's degree in Business/Criminal Justice/Healthcare

Descrição da oferta de emprego

Position Purpose

Conduct fraud, waste, and abuse (FWA) investigations by reviewing referrals, claims data, medical records, provider information, and other relevant evidence to identify potential misconduct and support case resolution. Document investigative activities, prepare reports and referrals, collaborate with internal and external stakeholders, and support program integrity efforts while ensuring compliance with applicable laws, regulations, contractual obligations, and organizational standards.

Key Details

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J -1, OPT, or CPT.

• Conducts fraud, waste, and abuse (FWA) investigations utilizing referrals, claims data, medical records, interviews, data analytics, and other investigative resources to identify potential misconduct and support case resolution.
• Analyzes, documents, and maintains investigative activities, findings, recommendations, and outcomes in accordance with established procedures, regulatory requirements, and service standards.
• Reviews claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns.
• Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate.
• Collaborates with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigative activities, support corrective actions, recoveries, and case resolution efforts.
• Supports audits, overpayment identification and recovery efforts, regulatory responses, special projects, and other program integrity initiatives.
• Maintains compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures.
• Monitors for emerging fraud schemes, billing irregularities, and trends that may present risks to healthcare programs and recommend appropriate actions for further review.
• Supports investigative case progression through onsite audits, visits, drive-by and additional investigative activities such as a member, provider, witness interviews, etc.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience

• Bachelor's Degree Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience required.
• 2+ years Fraud, waste, and abuse investigations, healthcare investigations, claims audits, payment integrity, healthcare compliance, law enforcement investigations, or a related investigative field required.
• Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development, preferred preferred.

Licenses/Certifications

• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE)[MF1.1], Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or other related investigative, auditing, or compliance certification. preferred

Pay Range: $56,200.00 - $101,000.00 per year

About Centene

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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