[Hiring] Manager, SIU Prepay Investigations @Centene Corporation

Role Description

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.

• 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.

Qualifications

• 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.

Requirements

• Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field or office work schedules.