Job Description

Job 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: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.

• Conduct investigations of potential waste, abuse, and fraud
• Document activity on each case and refer issues to the appropriate party
• Perform data mining and analysis to detect aberrancies and outliers in claims
• Develop new queries and reports to detect potential waste, abuse, and fraud
• Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions
• Assist with complex allegations of healthcare fraud
• Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies
• Complete various special projects and audits
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Bachelor’s Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 1+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience.

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

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