Manager, Special Investigation Unit – Pharmacy

🔥 14 hours ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $87.7k - $157.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Develop, implement and manage strategic fraud, waste and abuse activities while 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 to appropriately investigate all possible fraud, waste and abuse referrals • Develop educational materials to address and 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 post-payment cases with appropriate parties to obtain refunds • Prepare and distribute monthly and quarterly savings reports • Participate in Appeals Committee, work groups and interdepartmental meetings

🎯 Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience required • 4+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience required • Thorough knowledge of medical terminology required • Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred • Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred • Pharmacy or Pharmacy Benefit Manager (PBM) experience, and/or pharmacy technician credentials or experience preferred • Certified Pharmacy Technician (CPhT), medical records or coding license preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation