Manager, SIU Prepay Investigations

Centene Corporation•New York, NY

1d•$87,700 - $157,800•Hybrid

About The Position

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 activities by 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.

Requirements

Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience.
4+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience.
Thorough knowledge of medical terminology.

Nice To Haves

Previous experience as a lead or supervisor in a pre-payment process managing cross functional teams or supervisory experience including hiring, training, assigning work and managing the performance of staff preferred.
Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.
Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred

Responsibilities

Lead a team responsible for investigating fraud, waste and abuse referrals for prepay investigations
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 pre-payment cases with appropriate parties for the purposes of developing resolution strategies
Prepare and distribute monthly and quarterly saving reports
Participate in Appeals Committee, work groups and interdepartmental meetings