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SIU Investigator
Centene Corporation. Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting fraud, waste, and abuse investigations within the healthcare sector, utilizing data analytics and investigative resources to analyze claims and medical records. Proficient in preparing detailed reports and collaborating with various stakeholders to ensure compliance with regulations and organizational policies.
Highest-signal resume keywords
Fraud InvestigationHealthcare Claims AnalysisRegulatory ComplianceData AnalyticsReport Preparation
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Fraud InvestigationHealthcare Claims AnalysisData AnalyticsReport PreparationBilling and Coding DocumentationFinancial Record ReviewProvider Data AnalysisInvestigative ProtocolsAudit SupportCase Development
Soft Skills
CollaborationCommunicationAnalytical ThinkingProblem SolvingAttention to Detail
Industry Keywords
FraudWasteAbuseHealthcareComplianceInvestigative ResourcesEconomic InvestigationsInsurance ClaimsRegulatory ResponsesProgram Integrity
About the role
Key responsibilities & impact- Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources
- Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes
- Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation
- Prepare investigative reports, case summaries, referrals, and supporting documentation
- Collaborate with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies
- Support audits, overpayment identification and recovery efforts, regulatory responses, special projects, and program integrity initiatives
- Monitor emerging fraud schemes, billing irregularities, and trends and recommend appropriate actions
- Support case progression through onsite audits, visits, drive-by activities, and interviews
- Perform other duties as assigned and comply with all policies and standards
Requirements
What you’ll need- Bachelor's Degree in Business, Criminal Justice, Healthcare, or related field, or equivalent experience required
- 5+ years in healthcare working in fraud, waste and abuse investigations and audits, or 5+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or 7+ years of professional investigation experience involving economic or insurance related matters required
- Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development preferred
- Must be authorized to work in the U.S. without employment-based visa sponsorship now or in the future
- Must comply with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation