Centene is transforming the health of our communities one person at a time. As an Executive on our team, you could be the one who changes everything for our 28 million members.
Applicants for this role will have the flexibility to work remotely anywhere in the Continental United States.
Position Purpose:
Lead a team of investigators, clinical and coding reviewers, and analysts dedicated to detecting, preventing, and correcting fraud, waste, and abuse (“FWA”) in healthcare billing through investigation and coordination with internal and external stakeholders. Responsible for designing and executing strategies that ensure high-quality, timely, value-generating FWA investigations in compliance with legal, regulatory, and contractual requirements. Provide oversight of FWA investigative activity affecting Centene’s markets and products and partners closely with colleagues throughout the business, as well as external stakeholders, including law enforcement.
- Lead and support enterprise-wide SIU team that detects, investigates, and mitigates FWA across all business lines.
- Develop and execute a forward-looking FWA investigation strategy aligned with regulatory obligations and business priorities.
- Partner with colleagues in Compliance and Legal to ensure investigations and reporting meet federal and state mandates, including CMS and state Medicaid program requirements.
- Oversee the intake, triage, investigation, and resolution of suspected FWA cases.
- Drive implementation of technology and analytics tools to proactively identify risk patterns and trends.
- Establish KPIs and operational dashboards to monitor team performance, ensure case quality, and promote efficiency.
- Maintain clear documentation and governance frameworks for SIU operations and decision-making.
- Stay apprised of FWA-related developments and trends in the healthcare industry and share actionable knowledge and guidance with colleagues to help defend Centene and its members and customers against FWA.
- Serve as a trusted partner to market, product, and operational leadership to assist in identifying vulnerabilities and embedding FWA prevention controls in key processes.
- Cultivate external partnerships with regulators, state and federal law enforcement, and national FWA coalitions to share insights and align on best practices.
- Ensure timely and accurate reporting of FWA metrics and case data to appropriate regulatory bodies and Centene’s executive leadership.
- Act as a member of the Compliance Department leadership team and participate in policy development, training, communication, planning, and other departmental leadership activities.
- Represent the SIU at audit, board, and regulatory meetings as appropriate.
- Demonstrate Centene’s core values of Accountability, Curiosity, Courage, Trust, and Service in day-to-day communication and action.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
- Bachelor’s Degree in Business Administration, Healthcare Administration, Law, or related field required; Master’s Degree in Business Administration, Healthcare Administration, Law, related field or Juris Doctor (JD) preferred
- 10+ years progressive experience in fraud investigations, healthcare compliance, or regulatory enforcement. required
- Significant experience managing large-scale FWA programs in a health plan, payer, government agency, or consulting firm. required
- Deep knowledge of federal and state health programs (Medicare, Medicaid) and FWA regulatory frameworks (e.g., CMS, SIU mandates). required
- Proven leadership experience with cross-functional teams, external regulators, and law enforcement entities. required
- Strong data literacy and familiarity with fraud analytics tools and methodologies. required
- Excellent executive communication, risk judgment, and ethical decision-making skills. required
- Experience leading SIU operations in a multi-state or national managed care organization. preferred
- Ability to operate effectively in a complex, matrixed environment. preferred
- Track record of innovation in fraud detection and use of emerging technologies. preferred
- Deep commitment to Centene’s mission of transforming the health of the community, one person at a time. preferred
Licenses/Certifications:
Pay Range: $182,100.00 – $345,600.00 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, 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
