Manager, SIU Prepay Investigations

🔥 26 minutes ago

🐊 Florida, New York, +2 more states – Remote

🐊 Florida – Remote 🗽 New York – Remote 🏰 Missouri – Remote 🎸 Tennessee – Remote

💵 $87.7k - $157.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• 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

🎯 Requirements

• 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.

🏖️ 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