You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.Position Purpose: Develop, implement and manage strategic fraud, waste and abuse (FWA) activities by maintaining state and federal requirements and monitoring trends/schemes. 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
Education/Experience: 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.License/Certificates: Medical records, fraud investigation or coding license preferred.Pay Range: $103,500.00 - $191,600.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
