SIU Investigator

Centene Corporation; United States; Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Remote work

Hybrid work

401K

Stock purchase plan

Job summary

Centene Corporation is seeking a dedicated FWA Investigator to conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, and interviews. You will document activities, prepare reports, and collaborate with internal and external stakeholders to support program integrity and case resolutions.

You will review claims, provider billing practices, enrollment data, and financial records to identify issues, prepare referrals, and assist with corrective actions.

Qualifications

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

Responsibilities

• Conduct FWA investigations using referrals, claims data, medical records, interviews, data analytics, and other resources to identify misconduct and support case resolution.
• Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes per procedures and regulations.
• Review claims, medical records, provider billing practices, enrollment information, and other docs to identify fraud, waste, abuse, or overpayments.

Skills

Investigation experience

Healthcare data analysis

Documentation

Education

Bachelor's degree or related field

Tools

AHFI

CFE

CPC

CPMA

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.

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

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.

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