SIU Investigator

Centene Management Company LLC; United States; 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 a professional to investigate allegations of potential healthcare fraud and conduct claims investigations. Applicants should hold a Bachelor's Degree in a related field and have over one year of experience in medical claim analysis or fraud investigation.

The position offers a competitive salary range of $56,200 to $101,000 per year and various benefits such as health insurance, 401K, tuition reimbursement, and paid time off. Flexible work arrangements are available.

Qualifications

• 1+ years of medical claim investigation, medical claim audit, or fraud investigation experience required.

Responsibilities

• Investigate allegations of potential healthcare fraud and abuse activity.
• Assist in planning and organizing claims investigations or audits.
• Document activity on each case and refer issues to the appropriate party.
• Develop new queries and reports to detect potential waste, abuse, and fraud.
• Prepare reports on investigative findings for referral to Federal and State agencies.

Skills

Medical claim investigation

Fraud investigation

Data mining

Education

Bachelor's Degree in Business, Criminal Justice, Healthcare

Job description

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. 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.

Responsibilities

• Investigate allegations of potential healthcare fraud and abuse activity.
• Assist in planning, organizing, and executing claims investigations or audits.
• 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.
• Perform other duties as assigned.

Qualifications

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

Compensation

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

Benefits

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.

Equal Opportunity Employer

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.