Description
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.
Position Purpose: Independently leads complex fraud, waste, and abuse (FWA) investigations involving providers, members, pharmacies, vendors, and other entities. Utilizes advanced investigative techniques, data analysis, and case development strategies to identify potential misconduct, support corrective actions and recoveries, and resolve high-risk matters. Serves as a subject matter resource for investigative staff and prepares comprehensive findings, referrals, and recommendations for leadership, regulatory agencies, and law enforcement entities, as appropriate.
- Independently leads complex fraud, waste, and abuse (FWA) investigations involving providers, members, pharmacies, vendors, and other entities utilizing referrals, claims data, medical records, interviews, analytics, and other investigative resources.
- Analyzes and interprets complex claims, billing patterns, medical records, provider documentation, financial information, and other evidence to identify potential fraud, waste, abuse, overpayments, and compliance concerns.
- Develops investigative strategies, establish case direction, and manage investigations through resolution in accordance with applicable laws, regulations, contractual requirements, and organizational policies and procedures.
- Prepares comprehensive investigative reports, referrals, case summaries, and supporting documentation for leadership, regulatory agencies, law enforcement entities, and other authorized stakeholders.
- Serves as a subject matter resource to investigative staff by providing guidance on investigative techniques, case development, documentation standards, evidentiary requirements, and regulatory considerations.
- Collaborates with internal and external stakeholders, including Compliance, Legal, Payment Integrity, Provider Relations, government agencies, and law enforcement partners, to support investigative activities, corrective actions, recoveries, and case resolution.
- Identifies emerging fraud schemes, billing irregularities, control gaps, and program integrity risks, and recommend enhancements to investigative processes, monitoring activities, and analytical approaches.
- Supports audits, overpayment identification and recovery efforts, regulatory responses, special projects, enterprise initiatives, and other complex investigative matters.
- Ensures investigative activities meet established quality, timeliness, documentation, service level, and regulatory requirements.
- Assists in the development and delivery of training, knowledge sharing, and continuous improvement initiatives to support investigative effectiveness and program integrity objectives.
- Supports investigative case progression through onsite audits, visits, drive-by and additional investigative activities such as a member, provider, witness interviews, etc.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
- Bachelor's Degree Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience required.
- Master's Degree preferred
- 4+ years Conducting fraud, waste, and abuse investigations, healthcare fraud investigations, claims audits, payment integrity reviews, healthcare compliance investigations, law enforcement investigations, or related investigative work required.
- Experience leading complex investigations involving multiple data sources, extensive analysis, and coordination with internal and external stakeholders required.
- Experience preparing investigative reports, referrals, presentations, and supporting documentation for leadership, regulatory agencies, and law enforcement entities required.
- Experience interpreting and applying federal and state healthcare regulations, including Medicaid, Medicare, and other government-sponsored healthcare programs preferred.
- Additional qualifications may be required to satisfy applicable federal, state, regulatory, contractual, or program-specific requirements.
Licenses/Certifications:
- Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or other related investigative, auditing, or compliance 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
