Senior Compliance Oversight Specialist; RN

Position: Senior Compliance Oversight Specialist (RN)

Position Purpose Participate in the auditing, monitoring, and oversight of Centene's, its subsidiaries, and/or its third parties /subcontractors' corporate ethics and compliance program, and ongoing oversight and analysis of regulatory compliance issues. Conducts audit, oversight, and monitoring activities to assess compliance with aspects of Centene's contractual and regulatory requirements. Responsible for collaborating with business owners and/or third parties/subcontractors to drive remediation and assist Centene and third parties/subcontractors to maintain integrity through audit, oversight and monitoring and in meeting Government-sponsored health care program requirements.

Position Purpose Participate in the auditing, monitoring, and oversight of Centene's, its subsidiaries, and/or its third parties /subcontractors' corporate ethics and compliance program, and ongoing oversight and analysis of regulatory compliance issues. Conducts audit, oversight, and monitoring activities to assess compliance with aspects of Centene's contractual and regulatory requirements. Responsible for collaborating with business owners and/or third parties/subcontractors to drive remediation and assist Centene and third parties/subcontractors to maintain integrity through audit, overhead and monitoring and in meeting Government-sponsored health care program requirements.

Key

Details:

This is a remote position. Previous experience in Care Management and/or Utilization Management, as well as audit experience, is preferred.

• Prepare written reports on audit, oversight and monitoring activity findings and recommendations.
• Collaborate to direct compliance issues to appropriate channels for research and resolution.
• Review and evaluate the status and effectiveness of corrective action plans and provide comprehensive follow up.
• Support management in the development and maintenance of monitoring and auditing tools designed to evaluate internal and third party/subcontractor compliance with clinical aspects of government-sponsored health care program requirements, State Medicaid program annual work plans, and OIG and CMS work plans including but not limited to, care management utilization management, quality improvement plan management and oversight, and appeals.
• Educate, encourage, and assist those within the company and with the company’s third parties/subcontractors to maintain integrity through oversight and monitoring and in meeting the requirements of government-sponsored health care programs.
• Assist in the assessment of new and amended government-sponsored health care program contracts and requirements.
• Assist Health Plans, Subsidiaries, Shared Services, and Third Parties/Subcontractors in the identification and assessment of compliance risks.
• Serve as a compliance advisor to business units and third parties with specialized focus of care management, utilization management, quality improvement plan management and oversight activities, and appeals.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience

Bachelor’s degree in Nursing or related field required. 5+ years of related experience required.

License/Certification:

RN or LPN required. Certified in Health Care Compliance (CHC), Certified Compliance & Ethics Professional (CCEP);
Certified Internal Auditor (CIA); or Certified Fraud Examiner (CFE) 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…