PA Health & Wellness · 1 day ago
Senior SIU Investigator
Missouri, United States
Full-time
Onsite
Mid, Senior Level
$70K/yr - $126K/yr
3+ years expPA Health & Wellness is transforming the health of communities, and they are seeking a Senior SIU Investigator to investigate allegations of healthcare fraud and abuse. The role includes planning and executing special claims investigations, monitoring business processes, and preparing reports for referral to regulatory agencies.
FitnessHealth CareWellness
Responsibilities
Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment
Investigate possible waste, abuse and fraud leads and document activity on each lead and refer issues to the appropriate party
Develop internal reports to identify potential waste, abuse and fraud
Perform data mining and analysis to detect aberrancies and outliers in claims
Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud
Review post-payment cases with appropriate parties to obtain refund
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions
Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies
Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations
Qualification
Required
Bachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience
3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience
Preferred
Knowledge of Microsoft Applications
medical coding
claims processing
data mining
Certified Professional Coder
Benefits
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Company
PA Health & Wellness
Established to deliver quality healthcare in the state of Pennsylvania through local, regional and community-based resources, PA Health & Wellness is a Managed Care Organization and subsidiary of Centene Corporation (Centene).
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Justin Davis
President and Chief Executive Officer
Recent News
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