[Hiring] Senior Compliance Investigator @Centene Corporation

Role Description

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:

• Assist with the development, implementation, and continuous monitoring of an enterprise-wide Compliance Investigations Program.
• Lead the Company's Compliance Investigations for all Business Units, Health Plans, and Corporate functions.
• Oversee compliance and ethics investigations, facilitating meetings with business management and cross-functional stakeholders.
• Prepare, review, and analyze internal and external reporting.
• Support the Director, Ethics & Investigations in the day-to-day operations of the Compliance Investigations Unit (CIU).
• Conduct compliance and ethics investigations, including:
  • Assessment of allegations.
  • Review of relevant documents.
  • Witness interviews.
  • Analysis of facts.
  • Root cause analysis.
  • Preparation of investigation reports with recommended remedial or disciplinary actions.
• Independently evaluate and assess allegations to determine applicable criteria, including federal and state regulations, the Centene Code of Conduct, and internal policies.
• Adhere to Compliance Investigation workplans and protocols, conducting investigations in compliance with established protocols and timelines.
• Provide weekly case summaries and adhere to established minimum case review quotas.
• Ensure all investigative findings are clearly tied to applicable company policies, federal and state regulations, and maintain regulatory defensibility.
• Provide timely reports to the Director of Ethics & Investigations and/or senior management regarding the status and outcomes of investigations.
• Document, organize, and review case files within centralized case management systems (e.g., Archer) in accordance with Company policy and CIU protocols.
• Collaborate cross-functionally with other departments, including Legal, People Relations, SIU, Privacy, Finance, and Business Operations on investigations.
• Prepare and analyze departmental metrics, including investigation KPIs, case aging, and trending data, making recommendations accordingly.
• Prepare presentations and present findings to departmental and business management, executive leadership, and other stakeholders as needed.
• Identify risks, interpret investigation results, and recommend and communicate remedial actions to mitigate future potential risks.
• Perform follow-up to ensure remedial/disciplinary measures are implemented appropriately and timely.
• Assist with various projects as assigned by the Director of Ethics & Investigations or the VP of Compliance Investigations.
• Perform other duties as assigned.
• Comply with all policies and standards.

Qualifications

• 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.

Requirements

• 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.

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.