Manager, SIU Prepay Investigations

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: Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends and schemes.

• Monitor business processes and systems to assure integrity and compliance in billing and claims payment
• Lead a team responsible for investigating fraud, waste and abuse referrals for prepay investigations
• Develop educational materials to address/identify waste activities as requested by the health plan and on an ad-hoc basis
• Attend state/federal meetings as required by specific contracts
• Review pre-payment cases with appropriate parties for the purposes of developing resolution strategies
• Prepare and distribute monthly and quarterly saving reports
• Participate in Appeals Committee, work groups and interdepartmental meetings

Education/Experience: Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience. 4+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience. Thorough knowledge of medical terminology. Previous experience as a lead or supervisor in a pre-payment process managing cross functional teams or supervisory experience including hiring, training, assigning work and managing the performance of staff preferred. Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.

License/Certification: Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) 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