Remote Manager, Payment Integrity & Fraud Prevention

Centene Management Company LLC; Missouri; Hybride; USD 88 000 - 157 000; Plein temps

Avantages offerts par ce poste

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules (remote/hybrid

Résumé du poste

Centene Management Company LLC is seeking a seasoned Fraud, Waste and Abuse (FWA) professional to develop, implement and manage FWA activities across programs. You will lead analysts, monitor billing and claims processes, and ensure compliance with state and federal requirements.

Responsibilities include preparing reports, presenting findings to stakeholders, and guiding policy development to meet contractual obligations.

Qualifications

• Bachelor’s degree in Business, Healthcare, Criminal Justice, or related field.
• 4+ years of medical claim investigation, compliance or fraud and abuse experience.
• Thorough knowledge of medical terminology.
• Previous experience in managed care environment and as a lead or supervisor of staff.

Responsabilités

• Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes.
• Monitor business processes and systems to assure integrity and compliance in billing and claims payment.
• Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals.
• Develop customized fraud plans to meet contract and federal requirements.
• Develop educational materials to identify/validate 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/federal meetings as required by specific contracts.
• Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes.
• Review post‑payment cases with appropriate parties to obtain refund.
• Prepare and distribute monthly and quarterly saving reports.
• Performs other duties as assigned.
• Complies with all policies and standards.

Connaissances

Medical terminology

Leadership experience

Formation

Bachelor’s degree in Business/Healthcare/Criminal Justice

Description du poste

Centene Management Company LLC is seeking a seasoned Fraud, Waste and Abuse (FWA) professional to develop, implement and manage FWA activities across programs. You will lead analysts, monitor billing and claims processes, and ensure compliance with state and federal requirements.

Responsibilities include preparing reports, presenting findings to stakeholders, and guiding policy development to meet contractual obligations.