SIU Lead Investigator

Centene; United States; Remote; USD 68,000 - 124,000; Full time

Job summary

An established industry player is on the lookout for a dedicated Compliance Investigator to join their dynamic team. This role is essential in ensuring compliance and addressing fraud, waste, and abuse within healthcare. You will serve as a subject matter expert, guiding investigations while managing a diverse caseload. With a focus on community health, your contributions will directly impact the lives of millions. Enjoy a flexible work environment with competitive benefits, including health insurance and tuition reimbursement. If you have a passion for compliance and a desire to make a difference, this opportunity is perfect for you.

Benefits

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off

Flexible work schedules

Qualifications

• 5+ years of management experience in investigations and healthcare fraud.
• Bachelor’s degree or equivalent experience required.

Responsibilities

• Acts as a subject matter expert in compliance investigations.
• Logs, tracks, and resolves provider inquiries and complaints.
• Contributes to documentation for internal customer service agents.

Skills

Knowledge of Medicare and Medicaid laws

Reading and interpreting laws and regulations

Ability to work in a fast-paced environment

Intermediate Excel skills

SalesForce knowledge

Claims processing knowledge

Education

Bachelor’s degree in related field

Associate’s degree with 6 years of experience

High School/GED with 7 years of experience

Tools

Excel

Outlook

PowerPoint

Word

Xcelys

SalesForce

Microsoft Access

Job description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Position acts as a subject matter expert in the field of Compliance and/or Special Investigations Unit (SIU) investigations. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics.

• Serves as primary intake point for all provider issues and logs all provider inquiries.
• Works quickly, with great attention to detail, while managing competing priorities.
• Logs, tracks, resolves and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and WellCare Corporate guidelines in which special care is required to protect and enhance WellCare’s reputation.
• Works cross-functionally in preparation of effective communications with stakeholders on social channels and provides content to appropriately respond to social media posts regarding provider inquiries.
• Determines the nature and intent of social media comments including sentiment, urgency, and potential issues and implications.
• Serves as a subject matter expert for the Medicaid product line, primarily MMA reporting and assists internal functional areas with Medicaid questions and inquiries.
• Tracks & trends issues that result in AHCA complaints for purposes of developing preventive measures.
• Escalates customer service questions to other appropriate internal teams as needed.
• Supports the provider escalation project team to resolve claims and payment issues.
• Identifies root-cause issues to ensure enterprise solutions and communicate findings as needed.
• Shares case studies and best practices throughout the enterprise.
• Contributes to the creation of documentation such as SOPs, FAQs, and resources to be used by internal customer service agents.
• Researches escalated issues and takes appropriate action to resolve them within established service level agreements, WellCare best practice and quality standards.
• Applies a comprehensive knowledge of claims processing, provider customer service and payment knowledge to escalated provider inquiries.
• Assists with special projects as assigned.

Education/Experience: Bachelor’s degree in related field or Associate’s degree with 6 years of applicable experience, or a High School/GED with 7 years of applicable experience may substitute for the Bachelors Degree. 5+ years of management experience in investigations and healthcare fraud-related investigations with audit and risk analysis. 1+ year of experience in managed care or health insurance company.

Candidate Skills:

• In-depth knowledge of government programs, the managed care industry, Medicare, Medicaid laws and requirements, federal, state, civil and criminal statutes.
• Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources.
• Ability to work in a fast-paced environment with changing priorities.
• Intermediate Excel, Outlook, PowerPoint, Word, Xcelys, SalesForce, and Microsoft Access skills.
• Knowledge and understanding of managed care claims processing systems and medical claims coding preferred.

Licenses and Certifications: A license in one of the following is required: Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE). Other Pharmacy Investigator - Certified Pharmacy Technician.

Please note: This is a remote position; however, we have a strong preference for a candidate located within the state of PA.

Pay Range: $68,700.00 - $123,700.00 per year

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. Total compensation may also include additional forms of incentives.

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.