Remote Pharmacy SIU Manager - Fraud & Abuse

Centene Corporation; Missouri; Hybrid; USD 88,000 - 158,000; Full time

Job summary

Centene Corporation in Missouri is seeking a senior-level professional to develop, implement and manage strategic fraud, waste and abuse activities while ensuring state and federal compliance in billing and claims payment. You will lead investigations, supervise staff, and drive education materials to mitigate waste identified by health plans.

Your role includes attending regulatory meetings, reviewing post-payment cases for refunds, and delivering monthly and quarterly savings reports.

Qualifications

• 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.

Responsibilities

• Monitor business processes and systems to assure integrity and compliance in billing and claims payment
• Lead a team appropriately investigate all possible fraud, waste and abuse referrals
• Develop educational materials to address/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 refund
• Prepare and distribute monthly and quarterly saving reports
• Participate in Appeals Committee, work groups and interdepartmental meetings

Skills

Fraud investigation

Regulatory compliance

Leadership

Team management

Data analysis

Education

Bachelor’s degree in Business/Healthcare/Criminal Justice

Certified Pharmacy Technician (CPhT) or equivalent certification

Equivalent experience

Tools

Microsoft Excel

Medical coding

Claims processing

Data mining

Job description

Centene Corporation in Missouri is seeking a senior-level professional to develop, implement and manage strategic fraud, waste and abuse activities while ensuring state and federal compliance in billing and claims payment. You will lead investigations, supervise staff, and drive education materials to mitigate waste identified by health plans.

Your role includes attending regulatory meetings, reviewing post-payment cases for refunds, and delivering monthly and quarterly savings reports.