Senior Manager, Special Investigation Unit

Job not on LinkedIn

November 19

🏈 Ohio – Remote

Although this job is listed in Ohio, this company may be open to hiring remote in other states.

🌪️ Oklahoma – Remote

Although this job is listed in Oklahoma, this company may be open to hiring remote in other states.

💵 $105.6k - $195.4k / year

⏰ Full Time

🟠 Senior

👔 Manager

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Centene Corporation

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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.

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

📋 Description

• Develop, implement and manage strategic fraud, waste and abuse (FWA) activities by maintaining state and federal requirements and monitoring trends/schemes in Ohio and Oklahoma markets • Develop internal processes for enhanced FWA detection and investigation completion • Evaluate the department policies and procedures to ensure employee compliance and enhance daily processes • Prepare the annual audits complying with federal program regulations and participate in CMS audits and new business implementations • Monitor business processes and systems to assure integrity and compliance in billing and claims payment • Serve as a lead and investigate all possible fraud, waste and abuse referrals • Develop customized fraud plans to meet contract and federal requirements • Review educational materials to identify waste activities as requested by the health plan and on an ad-hoc basis • Respond to RFP request and implement new policies per contractual obligation • Attend state and federal meetings as required • Prepare and distribute monthly and quarterly saving reports • Performs other duties as assigned • Complies with all policies and standards

🎯 Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience • 6+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience • Thorough knowledge of medical terminology required • Experience in managed care environment and as supervisor of staff, including hiring, training, assigning work and managing performance • Knowledge of medical coding, claims processing, and data mining. • Medical records, fraud investigation or coding license 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