Lead SIU Investigator
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.
*This is a remote role anywhere within the continental US.*
Position Purpose: Position acts as a subject matter expert in the field of 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.
- Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse related matters.
- Assists manager on monitoring team caseload and report on metrics.
- Identifies training needs and develop training aids and step actions.
- Provides training and mentoring to team on casework and other SIU activities.
- Evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
- Conducts and documents interviews investigatory purposes.
- Reviews investigative interviews prepared by junior investigators.
- Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution.
- Thoroughly documents actions, organizes, and reviews case files.
- Consults with management, in-house counsel, and/or senior leadership to resolve difficult or complex issues.
- Identifies risks and recommends and communicates remedial actions to mitigate future potential risks.
- Performs follow up to ensure remedial and disciplinary measures are implemented appropriately and timely.
- Prepares clear and concise investigative plans and reports.
- Provides support and guidance to junior investigative staff.
- Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity.
- Attends, actively participates in, and/or leads meetings with various business area managers.
- Communicates directly with Federal or State regulators.
- Prepares cases for referral to management, government agencies, and law enforcement.
- Develops and maintains strong working relationships with associates and regulators.
- Testifies in criminal and civil matters.
- Participates in and lead special projects as needed.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
- Bachelor's Degree in related field; or Associate's degree with 6 years related experience; or High School Diploma/GED with 7 years related experience. required.
- Master's Degree preferred.
- 5+ years Healthcare fraud-related investigations with audit and risk analysis required.
- 1+ years Managed care or working with health insurance company required.
- In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes required.
- Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources required.
- Knowledge and understanding of managed care claims processing systems and medical claims coding preferred preferred.
Licenses/Certifications:
- Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or other industry related certification preferred.
Pay Range: $70,100.00 - $126,200.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition r