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.

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

Originally posted on Himalayas