Manager, SIU Intelligence – Innovation

🕒 Agosto 13

🐊 Florida, New York, +2 estados a mais – Remoto

🐊 Florida – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🏰 Missouri – Remote

💵 $87.700 - $157.800 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

👻 Score fantasma 1%

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Centene Corporation

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1984

🛡️ Seguros

💼 Consultoria

🏥 Saúde

Insurance • Consulting • Healthcare

Centene Corporation é uma provedora líder de serviços de saúde patrocinados pelo governo, especializada em oferecer soluções de saúde acessíveis e de alta qualidade. Há mais de 40 anos, a Centene tem se dedicado a transformar a saúde das comunidades, ampliando o acesso a Medicaid, Medicare e ao Health Insurance Marketplace, além de atender comunidades militares por meio do programa TRICARE. Como a maior organização de managed care do Medicaid e participante-chave no Marketplace, a Centene enfatiza a entrega de cuidados de saúde com foco local, combinada a parcerias sólidas com organizações sem fins lucrativos para atender às necessidades únicas de seus membros. A Centene também é comprometida com sustentabilidade corporativa e responsabilidade social, priorizando a gestão ambiental e a governança ética para promover o bem-estar das comunidades que atende.

Descrição

• Lead the strategic direction, development, and optimization of SIU capabilities supporting detection, prevention, and investigation of fraud, waste, and abuse (FWA) • Drive utilization of internal and external data assets, advanced analytic tools, predictive monitoring methodologies, and emerging technologies • Partner with SIU leadership, Medical Economics, Pharmacy, Compliance, and enterprise stakeholders to develop detection strategies and data-driven insights • Lead analytics personnel, enterprise data initiatives, modernization efforts, vendor relationships, and industry partnerships • Support planning, development, and execution of proactive anti-fraud detection and analytics programs • Manage, mentor, and develop team members, including hiring, performance management, training, coaching, and resource allocation • Optimize analytics resources including HCFS PostShield, AI Shield, Pharmacy Shield, and other data assets • Develop and implement analytic methodologies, dashboards, reporting solutions, and predictive monitoring capabilities • Evaluate emerging fraud schemes, industry risks, and analytical opportunities • Transform large, complex datasets into actionable intelligence for lead maturation, investigations, and fraud prevention • Support healthcare fraud analytics involving provider, member, pharmacy, and premium-related fraud detection • Facilitate data quality improvement, data remediation, and cross-functional enterprise and external data initiatives • Develop and maintain an SIU analytics roadmap with performance objectives, savings targets, value realization metrics, and operational outcomes • Oversee analytics-related vendor relationships and monitor performance • Represent SIU in data governance, analytics, innovation, and strategic planning forums • Communicate analytical findings, trends, risks, and recommendations to senior leadership and stakeholders • Lead cross-functional teams in fraud investigations and intelligence efforts • Monitor emerging fraud schemes and technological advancements • Collaborate with regulatory bodies and industry stakeholders • Manage training program development and implementation • Provide strategic recommendations to leadership and perform other duties as assigned

🎯 Requisitos

• Bachelor's degree in Data Analytics, Data Science, Business Analytics, Business or Healthcare Administration, Information Systems, Statistics, Computer Science, Criminal Justice, or a related field, or equivalent experience required • 5+ years of experience in healthcare analytics, fraud detection, SIU operations, program integrity, payment integrity, healthcare investigations, or related analytical functions • 2+ years conducting healthcare fraud investigations and knowledge of fraud, waste, and abuse trends and schemes • Experience leading, mentoring, coordinating, or managing analytical resources, projects, or teams • Experience developing and implementing advanced analytics, predictive monitoring, reporting, data visualization, and fraud detection methodologies using large and complex healthcare datasets • Experience collaborating with operational, compliance, investigative, and analytics stakeholders • Experience leading healthcare analytics, SIU, Program Integrity, Payment Integrity, Compliance, or FWA initiatives preferred • Experience with advanced analytics, predictive modeling, artificial intelligence, machine learning, fraud detection technologies, and external data resources preferred • Master's Degree preferred • Juris Doctor (JD) preferred • CFE, AHFI, CHC, PMP, SAS, CPC, or related certifications preferred • Compliance with all policies and standards

🏖️ Benefícios

• Competitive pay • Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Potential additional forms of incentives