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: Ensures the integrity, quality, and compliance of healthcare investigations through audits, process improvements, and collaboration with investigative teams. Combines analytical review, training, reporting, and some policy development to support organizational goals and regulatory standards.

• Conduct regular audits of Special Investigation Unit (SIU) and Compliance Investigation Unit (CIU) investigative case documentation and notes to ensure compliance with internal policies and procedures as well as demonstration of critical thinking and industry standards around healthcare fraud investigations.
• Assist in identification of trends, discrepancies, or potential areas of risk, providing actionable items to leadership.
• Develop and maintain audit tools, scorecards, and tracking systems to ensure consistent and objective reviews.
• Collaborate with Investigative teams and leadership to address audit findings and implement remediation plans.
• Support development and updates for investigative policies and procedures along with training materials based on audit results and findings.
• Monitor implementation of process changes to ensure sustained compliance and improved quality outcomes.
• Provide feedback and support to investigative leadership on documentation requirements, best practices, and quality standards.
• Participate in training sessions to support ongoing staff education related to compliance and investigation excellence.
• Prepare audit reports and present findings to management with clear insights and recommendations.
• Track performance metrics, compliance trends, and improvement initiatives to measure program effectiveness.
• Work closely with leadership to ensure alignment of audit activities with organizational goals.
• Participate in internal and external audits as needed.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Bachelor's Degree Business, Criminal Justice, Healthcare, related field or equivalent experience required. 3+ years experience in medical claim investigation, medical claim audit, medical claim analysis, SIU functions or healthcare fraud investigation or 2+ years with a relevant certification (CFE, AHFI,CIA,CHC,CPC or CPMA) required.


Licenses/Certifications Preferred:
Certified Fraud Examiner (CFE)
Healthcare Fraud Investigator Certification (HFIC)
Certified Internal Auditor (CIA)
Accredited Healthcare Fraud Investigator (AHFI)
Certified in Healthcare Compliance (CHC)

Pay Range: $56,200.00 - $101,000.00 per year

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