Senior Manager, Sales Investigations

🕒 il y a 18 jours

🐊 Florida, North Carolina, +2 états de plus – Distant

🐊 Florida – Remote 🌲 North Carolina – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

💵 $107 700 - $199 300 / an

⏰ Temps Plein

🟠 Senior

🤑 Commercial

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Centene Corporation

Site WebLinkedInTous les Emplois

10 000+ employés

Fondée en 1984

⚕️ Assurance santé

🤝 À but non lucratif

🌍 Impact social

Healthcare Insurance • Non-profit • Social Impact

La société Centene Corporation est un leader dans la fourniture de services de santé subventionnés par le gouvernement, spécialisée dans la délivrance de solutions de santé abordables et de haute qualité. Depuis plus de 40 ans, Centene s’est concentrée sur la transformation de la santé des communautés en élargissant l'accès aux services de Medicaid, Medicare, et au marché de l'assurance santé, tout en servant les communautés militaires à travers le programme TRICARE. En tant que plus grande organisation de gestion des soins Medicaid et un acteur clé du marché, Centene met l'accent sur une prestation de soins de santé localisée combinée à des partenariats solides avec des organisations à but non lucratif pour répondre aux besoins uniques de ses membres. Centene s’engage également pour le développement durable et la responsabilité sociale des entreprises, en privilégiant la gestion environnementale et la gouvernance éthique afin d'améliorer le bien-être des communautés qu’elle dessert.

Description

• Serves as a senior leader and subject matter expert, guiding and developing managers to build a high-performing, compliance-focused investigative team • Provides enterprise-wide leadership for the Sales Investigations Team (SIT), with direct oversight of day-to-day investigative operations • Directs the investigation of Medicare Advantage agent and agency misconduct allegations, including sales-related violations, fraud, waste, and abuse (FWA) concerns referred through hotline, regulatory, and special investigation channels • Provides enterprise-wide strategic and operational leadership for the Sales Investigations Team (SIT), including oversight of allegation intakes, regulatory-driven matters, and investigations involving sales practices, agent/agency conduct, and related FWA risks • Applies working knowledge of Medicare Advantage sales distribution structures, including FDR relationships, captive agent employment arrangements, and independent broker/agency contracts, to appropriately scope, contextualize, and adjudicate misconduct allegations • Establishes, maintains, and governs investigation standards, protocols, and quality controls (case triage, scoping, investigative plans, interviews, documentation, evidence handling, chain-of-custody, and retention) to ensure cases withstand regulatory, audit, and legal scrutiny • Sets interpretation standards for agent, agency, broker, and sales operations misconduct, including identification and assessment of novel or emerging schemes; recommend enterprise posture, mitigations, and corrective actions • Leverages data analysis and trend interpretation to identify systemic issues, serve as evidence within investigations, and drive enterprise-level corrective action strategies that demonstrably reduce recurrence and mitigate compliance risk • Directs coordination and communication with external stakeholders as appropriate, including CMS, state regulators, and law enforcement agencies; prepare and support responses to regulatory inquiries, audits, and investigations • Oversees and governs investigation-related policy and program frameworks, including sales investigations operating procedures, any program integration, and compliance training requirements and content • Leads, coaches, and develops multi-layer teams, including SIT managers and investigators; drive talent development, workload planning, and a culture of integrity, consistency, and continuous improvement • Ensures consistent application of investigative outcomes, including recommendations for disciplinary actions, contract actions, agent/agency remediation, corrective action plans, and control enhancements • Performs other duties as assigned • Complies with all policies and standards

🎯 Exigences

• Bachelor's Degree Compliance, Law, Criminal Justice or related field; or equivalent experience required • Master's Degree preferred • Juris Doctor (JD) preferred • 6+ years Compliance, investigations, law enforcement leadership, SIU, FWA, audit, and/or regulatory functions within managed care, a healthcare payor, or a similarly regulated environment required • 2+ years Leading people leaders and/or multi-layer teams preferred • Experience working with Medicare Advantage sales distribution structures, including the relationships and contractual obligations among first-tier, downstream, and related entities (FDRs) required • Experience working with Medicare Advantage sales distribution models, including first-tier, downstream, and related entity (FDR) structures, captive agent employment arrangements, and independent broker/agency contracting required • HCCA (CHC/CHPC), CFE, AHFI, CPCI, CPA, CIA, or other industry-related certification preferred

🏖️ Avantages

• 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