SIU Investigator

Centene Management Company LLC; Texas; Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Management Company LLC is seeking an experienced investigator to conduct fraud, waste, and abuse (FWA) investigations. You will review referrals, claims data, medical records, and provider information to identify misconduct and support case resolution, while ensuring compliance with laws, regulations, and internal standards.

Responsibilities include documenting findings, preparing reports and referrals, and collaborating with compliance, legal, provider and payment integrity teams,

Qualifications

• Bachelor's degree or equivalent experience required.
• 2+ years in fraud, waste, and abuse investigations or related field.
• Experience analyzing healthcare claims, medical records, billing documentation, or related records.

Responsibilities

• Conduct FWA investigations reviewing referrals, claims data, medical records, provider information and other evidence.
• Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders and regulatory agencies.
• Collaborate with internal teams and external agencies to coordinate investigative activities, corrective actions, recoveries, and case resolution.

Skills

Fraud investigations

Data analysis

Healthcare compliance

Education

Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or related field

Job description

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. 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

Company Culture

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.

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

Diversity and Inclusion

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.

Mission

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.