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:
Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes
- Oversee Coordination of Benefits (COB), Third Party Liability (TPL), and Subrogation recovery activities, including identification of other coverage, validation of recovery opportunities, coordination with internal operational teams, and timely resolution of provider, member, and carrier-related issues
- Monitor internal and vendor and platform performance for COB/TPL/Subrogation programs, including savings, inventory, cycle times, quality outcomes, and adherence to recovery policies and regulatory requirements
- 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
Education/Experience:
Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience. 4+ years of medical claim investigation, compliance or fraud and abuse experience. Thorough knowledge of medical terminology required. Experience with Coordination of Benefits (COB), Third Party Liability (TPL), Subrogation, or healthcare recovery operations preferred. Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred.
License/Certification: Medical records or coding license 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
