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About the Role
Conduct fraud, waste, and abuse (FWA) investigations by reviewing referrals, claims data, medical records, provider information, and other relevant evidence to identify potential misconduct and support case resolution. Document investigative activities, prepare reports and referrals, collaborate with internal and external stakeholders, and support program integrity efforts while ensuring compliance with applicable laws, regulations, contractual obligations, and organizational standards.
Responsibilities
- Conducts fraud, waste, and abuse (FWA) investigations utilizing referrals, claims data, medical records, interviews, data analytics, and other investigative resources to identify potential misconduct and support case resolution.
- Analyzes, documents, and maintains investigative activities, findings, recommendations, and outcomes in accordance with established procedures, regulatory requirements, and service standards.
- Reviews claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns.
- Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate.
- Collaborates with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigative activities, support corrective actions, recoveries, and case resolution efforts.
- Supports audits, overpayment identification and recovery efforts, regulatory responses, special projects, and other program integrity initiatives.
- Maintains compliance with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies and procedures.
- Monitors for emerging fraud schemes, billing irregularities, and trends that may present risks to healthcare programs and recommend appropriate actions for further review.
- 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.
Requirements
- Candidates who reside within the state of New York are highly preferred.
- Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
- Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J -1, OPT, or CPT.
- Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
Skills
- fraud, waste, and abuse (FWA) investigations
- reviewing referrals
- claims data analysis
- medical records review
- provider information analysis
- case resolution support
- investigative documentation
- report preparation
- collaboration with stakeholders
- program integrity support
- compliance with laws and regulations
- interviewing
- data analytics
- audits
- overpayment identification
- regulatory response
- special projects
- monitoring fraud schemes
- billing irregularities analysis
- trend analysis
- onsite audits
- provider visits
- drive-by investigations
- member interviews
- provider interviews
- witness interviews
Location
- New York (preferred)
Work Type
- remote
- hybrid
- field
- office
Experience Level
- 5+ years in healthcare field working in fraud, waste and abuse investigations and audits
- 5+ years of insurance claims investigation experience
- 5+ years of professional investigation experience with law enforcement agencies
- 7+ years of professional investigation experience involving economic or insurance related matters
Education Level
- Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience
Salary/Compensations
- $56,200.00 - $101,000.00 per year
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work
About the Company
- At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Equal Opportunity
- 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.