Position Purpose: Investigate allegations of healthcare fraudulent activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.
Bachelor’s Degree in Business, Healthcare, Criminal Justice, related field or equivalent experience. 3+ years of medical claim investigation or fraud investigation experience. Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.
Licenses/Certifications: Certified Professional Coder preferred
• Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment.
• Investigate possible waste error, abuse and fraud leads. Document activity on each lead and refer issues to the appropriate party.
• Develop internal reports to identify potential waste error, abuse and fraud.
• Review high dollar claim and post payment review reports, medical records, and itemized bills to identify issues and recommend changes.
• Serve as contact for corporate and field regarding waste errors, abuse and fraud.
• Communicate incorrect payments to appropriate parties for pre-payment cases.
• Review post-payment cases with appropriate parties to obtain refund.
• Serve as a mentor/coach for SIU Analysts and SIU Investigators.
Centene Corporation - 18 months ago
Centene is sensitive to the needs of individuals and families enrolled in government-assisted health programs. The company provides managed...