SIU Investigator

Centene Management Company; Texas; Hybride; USD 56 000 - 101 000; Plein temps

Avantages offerts par ce poste

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Remote, hybrid, field or office work

Résumé du poste

Centene Management Company seeks an experienced investigator to conduct fraud, waste, and abuse (FWA) investigations in a healthcare setting in Texas. You will use referrals, claims data, and interviews to identify potential misconduct and support case resolution.

You will analyze and document investigative activities, coordinate with compliance, legal, and external agencies, and assist with audits and recovery efforts. The role requires 2+ years in relevant investigations and a related degree.

Qualifications

• Bachelor's degree in a related field or equivalent experience.
• 2+ years FWA investigations or related healthcare investigations.
• Experience analyzing healthcare claims, medical records, billing documentation, or related records.

Responsabilités

• Conducts FWA investigations using referrals, claims data, medical records, interviews, and data analytics to identify misconduct and support case resolution.
• Analyzes, documents, and maintains investigative activities, findings, and outcomes in line with procedures, regulations, and service standards.
• Reviews claims, medical records, provider billing practices, enrollment information, and financial records for potential fraud, waste, or compliance concerns.
• Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulators, or law enforcement as appropriate.
• Collaborates with compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigations and corrective actions.
• Supports audits, overpayment identification and recovery efforts, regulatory responses, and program integrity initiatives.
• Maintains compliance with applicable federal/state regulations, privacy standards, and investigative protocols.
• Monitors emerging fraud schemes and billing irregularities to identify risks and recommend actions for review.
• Supports case progression through onsite audits, visits, and witness interviews.
• Performs other duties as assigned and complies with policies.

Connaissances

FWA investigations

Data analytics

Interviews

Medical records review

Regulatory compliance

Audit support

Formation

Bachelor's degree in related field

2+ years investigative experience

Description du poste

Position Purpose:

• 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.

Licenses/Certifications:

• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), 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

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