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Director, Claims Compliance and Program Operations

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This job is available in 3 locations

Director, Claims Compliance and Program Operations

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Description

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.

Applicants for this role will need to reside in Florida, Missouri or California going into the office occasionally.

Position Purpose: Collaborates with the business and internal/external key stakeholders to create, implement, and lead a system of controls to assess. Monitors operations, risk management processes, evaluates, and operationalizes strategies, and leads implementation of compliance/business initiatives. Executes operations to foster an ethical leadership culture, demonstrates adherence to federal/state regulatory guidelines, and corporate policies, for an effective compliance and ethics program. Provides regulatory advice and guidance, monitors legislation/regulation updates, reporting and data analytics, and ensures training is updated, delivered, and completed by required parties.

  • Provide guidance and support on all policy and standards issues to executive management in carrying out the compliance program.
  • Monitors and interpret changes in laws, regulations, and best practices.
  • Ensure compliance with contractual requirements and federal and state government reporting and regulations. Maintain government relations for compliance activities.
  • Design and execute controls for operational and compliance excellence.
  • Responsible for the mining of data across multiple sources of information to provide actionable results.
  • Provide reports on a regular basis, and as directed or requested, to keep senior management informed of the operation and progress of compliance efforts.
  • Oversee and monitor the implementation of risk management with identification, escalation, and mitigation of operational risk.
  • Documentation of end-to-end monitoring system of controls; Strong collaboration with key stakeholders to understand life cycle points of entry and exit.
  • Establish operational control framework and governance with oversight and drive control-related initiatives.
  • Ensure control and process discipline are rigorously maintained.
  • Measure, interpret processes to proactively implement a best-in-class system.
  • Performs other duties as assigned.
  • Complies with all policies and standards.

Education/Experience:

  • Bachelor's degree in business or related field. Master’s degree preferred.
  • 7+ years of professional management level experience in healthcare operations, compliance, finance, or program management required.
  • Knowledge and research of compliance regulations and practices, specifically as they relate to healthcare products required.
  • 3+ years of supervisory/management experience required.
  • Direct Medicare Appeals experience highly preferred.
  • Project management experience preferred. Large healthcare transformational project experience preferred.


License/Certification:

Six Sigma Black Belt certification preferred.

Pay Range: $142,300.00 - $263,500.00 per year

Centene 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.

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