Skip to content
Senior SIU Investigator
| Company | Centene |
|---|
| Location | Pennsylvania, USA |
|---|
| Salary | $68700 – $123700 |
|---|
| Type | Full-Time |
|---|
| Degrees | Bachelor’s |
|---|
| Experience Level | Senior |
|---|
Requirements
- Bachelor’s Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience
- 3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience
- Knowledge of Microsoft Applications, medical coding, claims processing, and data mining preferred
Responsibilities
- Investigate allegations of healthcare fraud and abuse activity
- Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud
- Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment
- Investigate possible waste, abuse and fraud leads and document activity on each lead and refer issues to the appropriate party
- Develop internal reports to identify potential waste, abuse and fraud
- Perform data mining and analysis to detect aberrancies and outliers in claims
- Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud
- Review post-payment cases with appropriate parties to obtain refund
- Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions
- Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies
- Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations
Preferred Qualifications
- Candidates located within PA are highly preferred
