Insurance Company Investigator Jobs in Reston, VA

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Under the general direction of the VP of Compliance Investigations this position assists with the development, implementation, and continuous monitoring of an enterprise-wide Compliance Investigations Program and leads the Company's Compliance Investigations for all Business Units, Health Plans, and Corporate functions. Leads and oversees compliance and ethics investigations, facilitates and leads meetings with business management and cross-functional stakeholders, and prepares, reviews, and analyzes internal and external reporting. Supports the Director, Ethics & Investigations in the day-to-day operations of the Compliance Investigations Unit (CIU).

• Leads and conducts compliance and ethics investigations across all business units and health plans, including but not limited to assessment of allegations, review of relevant documents, witness interviews, analysis of facts, root cause analysis, and preparation of investigation reports with recommended remedial or disciplinary actions.
• Independently evaluates and assesses allegations to determine applicable criteria, including federal and state regulations, the Centene Code of Conduct, and internal policies, procedures, and standards that are alleged to have been violated.
• Adheres to Compliance Investigation workplans and protocols and conducts investigations in compliance with established protocols and timelines.
• Provides weekly case summaries and adheres to established minimum case review quotas to ensure timely progression and resolution of the investigative caseload.
• Ensures all investigative findings are clearly tied to applicable company policies (e.g., Code of Conduct), federal and state regulations, and to maintain regulatory defensibility and support appropriate remediation.
• Provides timely reports, both orally and in writing, to the Director of Ethics & Investigations and/or senior management regarding the status and outcomes of investigations.
• Thoroughly documents, organizes, and reviews case files within centralized case management systems (e.g., Archer) in accordance with Company policy and CIU protocols.
• Collaborates cross-functionally with other departments, including Legal, People Relations, SIU, Privacy, Finance, and Business Operations on investigations and the investigative process.
• Prepares and analyzes departmental metrics, including investigation KPIs, case aging, and trending data, and makes recommendations accordingly.
• Prepares presentations and presents findings to departmental and business management, executive leadership, and other stakeholders as needed.
• Identifies risks, interprets investigation results, and recommends and communicates remedial actions to mitigate future potential risks.
• Performs follow-up to ensure remedial/disciplinary measures are implemented appropriately and timely, including tracking remediation activities through case management systems.
• Assists with various projects as assigned by the Director of Ethics & Investigations or the VP of Compliance Investigations.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience:

• A Bachelor's Degree in Related Field or Associates with 5 years of applicable experience, or a High School/GED with 6 years of applicable experience may substitute for the Bachelor's Degree, required.
• 4+ years of experience in investigations, auditing and risk analysis required.
• 1+ year of experience in reading, analyzing and interpreting State and Federal laws, rules and regulations required.

Preferred Qualifications:

• Managed care or health insurance company experience preferred.
• Experience with compliance case management systems (e.g., Archer, Navex) preferred.
• Demonstrated experience conducting ethics and compliance investigations in a regulated healthcare environment preferred.
• Experience collaborating with cross-functional teams including Legal, People Relations, SIU, and Privacy preferred.

Licenses and Certifications:

• Certified Fraud Examiner (CFE) preferred.
• Certified Compliance & Ethics Professional (CCEP) or Certified Healthcare Compliance (CHC) preferred.

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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