Manager, Special Investigation Unit – Pharmacy

Centene Corporation

. Develop, implement and manage strategic fraud, waste and abuse activities while maintaining state and federal requirements and monitoring trends and schemes .

Posted 10/23/2026full-timeRemote • Missouri • United StatesMid-LevelSenior💰 $87,700 - $157,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in fraud, waste, and abuse management within healthcare, ensuring compliance with state and federal regulations. Proficient in medical claim investigation, financial impact analysis, and developing educational materials for waste identification.

Highest-signal resume keywords

Fraud, Waste, And Abuse ManagementMedical Claim InvestigationFinancial Impact AnalysisCompliance MonitoringTeam Leadership

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical TerminologyClaims ProcessingData MiningFinancial AnalysisBusiness AnalysisFraud InvestigationMedical CodingBilling IntegrityTrend MonitoringRefund Processing

Soft Skills

Team LeadershipCommunicationTrainingPerformance ManagementCollaboration

Tools & Technologies

Microsoft Excel

Certifications & Qualifications

Certified Pharmacy Technician (CPhT)Medical Records LicenseCoding License

Industry Keywords

Managed CareHealthcare CompliancePharmacy Benefit Manager (PBM)Fraud PreventionWaste Identification

About the role

Key responsibilities & impact

Develop, implement and manage strategic fraud, waste and abuse activities while maintaining state and federal requirements and monitoring trends and schemes
Monitor business processes and systems to assure integrity and compliance in billing and claims payment
Lead a team to appropriately investigate all possible fraud, waste and abuse referrals
Develop educational materials to address and identify waste activities as requested by the health plan and on an ad-hoc basis
Attend state/federal meetings as required by specific contracts
Review post-payment cases with appropriate parties to obtain refunds
Prepare and distribute monthly and quarterly savings reports
Participate in Appeals Committee, work groups and interdepartmental meetings

Requirements

What you’ll need

Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience required
4+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience required
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
Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred
Pharmacy or Pharmacy Benefit Manager (PBM) experience, and/or pharmacy technician credentials or experience preferred
Certified Pharmacy Technician (CPhT), medical records or coding license preferred

Benefits

Comp & perks

Competitive pay
Health insurance
401K plan
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Additional forms of incentives may be included in total compensation