Manager, SIU Intelligence – Innovation

🔥 0 minutes ago

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

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

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

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

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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