Position Purpose:
Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes

• Lead Outstanding Claims Recovery and Accounts Receivable operations, with accountability for outstanding inventory, aging, collections, provider offsets/refunds, and financial recovery results.
• Manage and develop staff responsible for recovery and receivable activities, including workload prioritization, performance management, coaching, and accountability for results.
• Lead complex recovery / Negative Balances initiatives and large cross-functional meetings, partnering with Claims, Finance, Provider/Network Operations, Health Plans, IT, and vendors to resolve barriers and improve recovery outcomes.
• Establish and monitor operational metrics, controls, and reporting to identify aging or stranded balances, manage collection risk, and drive process and technology improvements.
• Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals.
• Monitor business processes and systems to assure integrity and compliance in billing and claims payment.
• 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. Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred.

• Experience managing staff responsible for recovery inventories, receivables, collections, or claims-related financial operations preferred.
• Experience managing Outstanding Claims Recovery, Accounts Receivable, healthcare collections, provider recovery, or post-payment recovery operations preferred.
• Experience managing large or aging financial inventories and developing prioritization, escalation, and collection strategies preferred.
• Experience developing and monitoring operational and financial KPIs, including inventory aging, recovery dollars, collections, productivity, and outstanding receivables preferred.
• Experience leading large cross-functional initiatives and stakeholder meetings involving Claims, Finance, Provider/Network Operations, IT, and external vendors preferred.

License/Certification: Medical records or coding license preferred.

• Certified Revenue Cycle Representative (CRCR), Certified Revenue Cycle Professional (CRCP), or comparable certification preferred, particularly when supported by health plan claims recovery, payer receivables, or post-payment recovery experience.
• Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), or comparable payment integrity certification preferred.
• Project Management Professional (PMP) or comparable project/program management certification preferred.
• Other certifications related to health plan claims, payment integrity, accounts receivable, collections, or recovery operations preferred.

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
 

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