Senior Pharmacy SIU Investigator

Centene
Missouri, Georgia, Ohio, Florida, Indiana, New York, North Carolina, Illinois, Massachusetts, Connecticut, Pennsylvania, Texas, Kentucky
Workplace: RemoteFull timeUSD 70,100 - 126,200 annuallyFunction: Solutions Engineering & Sales EngineeringExperience: 4+ yearsEducation: bachelorsSkills: ["Independent investigation","Investigative analysis","Stakeholder coordination","Report writing","Regulatory awareness"]

Independently lead complex fraud, waste, and abuse (FWA) investigations across providers, members, pharmacies, vendors, and related entities. Analyze claims, billing patterns, medical records, and financial information to identify potential fraud, waste, abuse, overpayments, and compliance risks. Build investigative strategies and produce comprehensive reports, referrals, and recommendations for leadership, regulatory agencies, and law enforcement, while serving as a subject matter resource to investigative teams.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
Centene
Centene
1 day ago

Senior Pharmacy SIU Investigator

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 11 hours agoStatus: Live

Job Summary

Independently lead complex fraud, waste, and abuse (FWA) investigations across providers, members, pharmacies, vendors, and related entities. Analyze claims, billing patterns, medical records, and financial information to identify potential fraud, waste, abuse, overpayments, and compliance risks. Build investigative strategies and produce comprehensive reports, referrals, and recommendations for leadership, regulatory agencies, and law enforcement, while serving as a subject matter resource to investigative teams.
Location: Missouri, Georgia, Ohio, Florida, Indiana, New York, North Carolina, Illinois, Massachusetts, Connecticut, Pennsylvania, Texas, Kentucky
Workplace: Remote
Employment Type: Full time
Job Function: Solutions Engineering & Sales Engineering
Seniority: Mid level

Key Responsibilities

  • •Independently lead complex FWA investigations involving providers, members, pharmacies, vendors, and other entities using referrals, claims data, medical records, interviews, analytics, and related resources.
  • •Analyze complex claims, billing patterns, medical records, provider documentation, and financial information to identify potential fraud, waste, abuse, and compliance concerns.
  • •Develop investigative strategies and manage case direction through resolution in accordance with laws, regulations, contractual requirements, and organizational policies.
  • •Prepare comprehensive investigative reports, referrals, case summaries, and supporting documentation for leadership, regulatory agencies, and law enforcement.
  • •Serve as a subject matter resource to investigative staff by providing guidance on investigative techniques, case development, documentation standards, evidentiary requirements, and regulatory considerations.

Pay and Benefits

Salary: USD 70,100 - 126,200 annually
Perks:Health Insurance401kPaid LeaveRemote Work

Key Requirements

  • •Bachelor’s degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent experience.
  • •4+ years conducting fraud, waste, and abuse investigations, healthcare fraud investigations, claims audits, payment integrity reviews, healthcare compliance investigations, law enforcement investigations, or related work.
  • •Experience leading complex investigations using multiple data sources, extensive analysis, and coordination across internal and external stakeholders.
  • •Experience preparing investigative reports, referrals, presentations, and supporting documentation for leadership, regulatory agencies, and law enforcement.
  • •Experience interpreting and applying federal and state healthcare regulations, including Medicaid and Medicare (preferred).
Experience:4+ yearsHealthcareFraudComplianceInvestigations
Education:Bachelor's in Business, Criminal Justice, Healthcare Administration, Public Health, or related field
Skills:Independent investigationInvestigative analysisStakeholder coordinationReport writingRegulatory awareness
Certifications:Accredited Healthcare Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)Certified Professional Coder (CPC)Certified Professional Medical Auditor (CPMA)

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn