Sr. Special Investigation Unit Investigator
Centene Corporation - St. Louis, MO

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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.

Knowledge/Experience:
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

Position Responsibilities:

• 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 - save job - block
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About this company
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Centene is sensitive to the needs of individuals and families enrolled in government-assisted health programs. The company provides managed...