Special Investigation Unit Investigator
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Special Investigation Unit Investigator investigating healthcare fraud, waste, and abuse for Centene. Reviewing claims and records, preparing case reports, and supporting program integrity recoveries.
Responsibilities:
- 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 for potential fraud, waste, abuse, overpayments, or compliance concerns
- Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties
- Collaborate with business partners, compliance, legal, provider and payment integrity teams, and external agencies
- Support corrective actions, recoveries, audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives
- Monitor emerging fraud schemes, billing irregularities, and healthcare program risks and recommend appropriate actions
- Support case progression through onsite audits, visits, drive-by activities, and interviews
- Comply with all policies and standards and perform other duties as assigned
Requirements:
- Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience
- An Associates or Bachelor's degree in criminal justice or a related field; or employment as an investigator in the MMCO's SIU on or before the effective date of this SubPart
- Minimum of five (5) years in healthcare field working in fraud, waste and abuse investigations and audits, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance related matters
- Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development preferred
- AHFI, CFE, CPC, CPMA, or other related investigative, auditing, or compliance certification preferred
- Compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures
Benefits:
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
Similar Jobs
Special Investigations Unit Investigator
Special Investigations Unit Investigator administering CareOregon’s healthcare fraud, waste, and abuse program. Conducting investigations, audits, reporting, corrective actions, and provider education.
Civil Rights/Title IX Investigator
Civil rights investigator conducting impartial Title IX and discrimination investigations for education risk-management consultancy. Producing evidence-based reports and training institutional stakeholders.
Clinical Trial Investigator, Grant Forecasting
Clinical trial grant forecasting specialist supporting Thermo Fisher Scientific, a global science-services company. Building payment forecasts, dashboards, variance analyses, and scenarios across clinical studies and countries.
SIU Investigator
SIU Investigator conducting Workers’ Compensation and other insurance-claim fraud investigations for Delta Group. Interviewing claimants and witnesses, analyzing evidence, and reporting findings to insurers and clients.
Investigator Payments Lead – Associate
Investigator payments lead managing clinical site payments for Parexel, a global clinical research organization. Overseeing budgets, contracts, payment systems, vendors, and issue resolution across clinical trials.
Investigator Payments Lead – Senior Associate
Investigator Payments Lead managing clinical site payments, budgets, contracts, and vendor oversight for Parexel, a global clinical research organization. Supporting timely, accurate payments across clinical trials from study startup through closeout.
Investigator Payments Lead – Associate, Clinical Site Payments Lead – Associate
Investigator Payments Lead supporting Parexel’s global clinical trials from Romania. Managing site payment systems, budgets, contracts, vendors, and payment issue resolution.
Investigator Payments Lead – Senior Associate
Investigator Payments Lead managing clinical site payments for Parexel, a global clinical research organization. Overseeing budgets, contracts, payment systems, vendors, and payment execution across clinical trials.
Fire Investigator
Fire Investigator conducting origin-and-cause investigations for EFI Global, a forensic engineering and specialty consulting firm. Determining responsibility and delivering defensible findings across Texas.
Investigator, Grants Specialist
Investigator Grants Specialist forecasting and costing clinical-trial grants for Worldwide Clinical Trials, a global CRO. Collaborating across commercial, project, clinical, and site-activation teams.
Investigator Payments Lead – Senior Associate
Investigator Payments Lead managing clinical site payments for Parexel, a global clinical research organization. Overseeing budgets, contracts, payment systems, vendors, and study payment execution.
Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia
Investigator II handling insurance fraud investigations for West Bend, focusing on various personal, commercial, and specialty lines. Collaborating with internal stakeholders and external partners to evaluate and investigate suspicious transactions.
Senior Fire Investigator, IAAI-CFI
Fire Investigator conducting origin and cause investigations for EFI Global in a remote role. Seeking a self-directed professional with IAAI-CFI certification preferred and a commitment to integrity.
Senior Investigator
Senior Investigator managing fraud, waste, and abuse audits across independent teams at PacificSource. Conducting investigations and ensuring compliance with regulations and company policies.
Retail Crime Investigator
Retail Crime Investigator role with Weis Markets managing investigations of external theft. Responsible for collaborating with law enforcement and providing investigative support across multiple locations.
Investigator Support Coordinator – German/French/Italian Speaker
Remote Investigator Support Assistant notifying investigator sites of lab results and supporting inquiries. Requires fluency in English and Italian, German, or French.
Senior Fire Investigator – IAAI-CFI
Senior Fire Investigator conducting origin and cause investigations for EFI Global in the Dallas area. Collaborating with multidisciplinary teams to deliver unbiased findings in fire investigations.
Fire Investigator – IAAI-CFI
Fire Investigator conducting origin and cause investigations for EFI Global. Collaborating with a multidisciplinary team to provide reliable conclusions and exceptional service across the region.
Senior Investigator
Senior Investigator leading complex OSINT investigations to protect intellectual property rights. Collaborating with global teams in the Special Investigations Unit to combat infringement worldwide.
Senior Investigator
Senior Investigator leading complex OSINT investigations aimed at dismantling criminal operations. Focusing on intellectual property protection using advanced techniques and digital intelligence tools.