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.
Position Purpose: Leads the strategic direction, development, and optimization of SIU capabilities that support the detection, prevention, and investigation of fraud, waste, and abuse (FWA). Drives the effective utilization of internal and external data assets, advanced analytic tools, predictive monitoring methodologies, and emerging technologies to identify investigative opportunities and enhance organizational value realization.
Partners closely with Special Investigations Unit (SIU) leadership, Medical Economics, , Pharmacy, Compliance, and other enterprise stakeholders to develop innovative detection strategies, actionable intelligence, and data-driven insights that strengthen program integrity efforts. This position provides leadership for analytics personnel, enterprise data initiatives, strategic modernization efforts, vendor relationships, and industry partnerships while ensuring alignment with organizational objectives, regulatory requirements, and emerging fraud trends.
- Supports the strategic planning, development, and execution of SIU proactive anti-fraud detection and analytics programs, initiatives, and priorities.
- Manages, mentor, and develop team members, including hiring, performance management, goal setting, training, coaching, and resource allocation to ensure effective execution of departmental objectives and achievement of business results.
- Drives value realization and optimization of analytics resources, including HCFS PostShield, AI Shield, Pharmacy Shield, and other internal and external data assets to identify, develop, and optimize proactive analytic methodologies.
- Partners with enterprise stakeholders to identify, develop, and implement proactive analytic methodologies, dashboards, reporting solutions, and predictive monitoring capabilities.
- Evaluates emerging fraud schemes, industry risks, and analytical opportunities to enhance detection and investigative effectiveness.
- Transforms large, complex datasets into actionable intelligence that supports lead maturation, investigative development, and fraud prevention strategies.
- Supports strategic initiatives involving healthcare fraud analytics, including activities related to provider, member, pharmacy, and premium-related fraud detection.
- Facilitates enterprise and external data initiatives, including data quality improvement efforts, data remediation activities, and cross-functional collaboration with industry organizations and partnerships.
- Leads analytics strategy and support SIU transformation initiatives where data integration, fraud detection, and investigative analytics are critical components.
- Develops and maintain an SIU analytics roadmap with measurable performance objectives, savings targets, value realization metrics, and operational outcomes.
- Provides direct leadership, coaching, and development of assigned staff, ensuring appropriate resource allocation, capability development, and performance outcomes.
- Supports oversight of analytics-related vendor relationships and monitor performance against established objectives and service expectations.
- Represents SIU in enterprise data governance, analytics, innovation, and strategic planning forums.
- Integrates regulatory developments, external intelligence sources, industry trends, and collaborative partnerships into proactive fraud detection and investigative strategies.
- Communicates analytical findings, trends, risks, and recommendations to senior leadership and business stakeholders.
- Develops strategies and tools to enhance the identification of fraudulent activities and improve investigative outcomes.
- Leads cross-functional teams to ensure collaborative engagement in fraud investigations and intelligence efforts.
- Monitors emerging trends in fraud schemes and technological advancements to proactively adapt investigative practices.
- Collaborates with regulatory bodies and industry stakeholders to ensure compliance and alignment with best practices.
- Manages the development and implementation of training programs to enhance team expertise and effectiveness.
- Provides expertise and strategic recommendations to leadership to support decision-making and resource allocation.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
- Bachelor's Degree Bachelor's degree in Data Analytics, Data Science, Business Analytics, Business or Healthcare Administration, Information Systems, Statistics, Computer Science, Criminal Justice, or a related field; or equivalent experience required.
- Master's Degree preferred.
- Juris Doctor (JD) preferred.
- 5+ years Healthcare analytics, fraud detection, SIU operations, program integrity, payment integrity, healthcare investigations, or related analytical functions required.
- 2+ years Conducting healthcare fraud investigations and knowledge of fraud, waste, and abuse trends and schemes required.
- Experience leading, mentoring, coordinating, or managing analytical resources, projects, or teams required.
- Experience developing and implementing advanced analytics, predictive monitoring, reporting, data visualization, and fraud detection methodologies using large and complex healthcare datasets to generate actionable business insights and support operational decision-making required.
- Experience collaborating with cross-functional stakeholders across operational, compliance, investigative, and analytics functions to drive data-informed strategies related to healthcare fraud, waste, and abuse prevention, managed care operations, and organizational performance improvement required.
- Experience leading healthcare analytics, SIU, Program Integrity, Payment Integrity, Compliance, or fraud, waste and abuse (FWA) initiatives, including development of analytics strategies, roadmaps, performance metrics, value realization methodologies, and operational improvement efforts preferred.
- Experience applying advanced analytics, predictive modeling, artificial intelligence, machine learning, fraud detection technologies, and external data resources to support proactive fraud identification, complex investigations, vendor and partnership oversight, and compliance with healthcare regulatory and industry requirements preferred.
Licenses/Certifications:
- CFE, AHFI, CHC, PMP, SAS, CPC or other certifications related to healthcare fraud, analytics, investigations, project management, or data science preferred.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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
