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:
Serves as a senior leader and subject matter expert, guiding and developing managers to build a high-performing, compliance-focused investigative team. Provides enterprise-wide leadership for the Sales Investigations Team (SIT), with direct oversight of day-to-day investigative operations. Directs the investigation of Medicare Advantage agent and agency misconduct allegations, including sales-related violations, fraud, waste, and abuse (FWA) concerns referred through hotline, regulatory, and special investigation channels.
Provides enterprise-wide strategic and operational leadership for the Sales Investigations Team (SIT), including oversight of allegation intakes, regulatory-driven matters, and investigations involving sales practices, agent/agency conduct, and related FWA risks.
Applies working knowledge of Medicare Advantage sales distribution structures, including FDR relationships, captive agent employment arrangements, and independent broker/agency contracts, to appropriately scope, contextualize, and adjudicate misconduct allegations.
Establishes, maintains, and governs investigation standards, protocols, and quality controls (case triage, scoping, investigative plans, interviews, documentation, evidence handling, chain-of-custody, and retention) to ensure cases withstand regulatory, audit, and legal scrutiny.
Sets interpretation standards for agent, agency, broker, and sales operations misconduct, including identification and assessment of novel or emerging schemes; recommend enterprise posture, mitigations, and corrective actions.
Leverages data analysis and trend interpretation to identify systemic issues, serve as evidence within investigations, and drive enterprise-level corrective action strategies that demonstrably reduce recurrence and mitigate compliance risk.
Directs coordination and communication with external stakeholders as appropriate, including CMS, state regulators, and law enforcement agencies; prepare and support responses to regulatory inquiries, audits, and investigations.
Oversees and governs investigation-related policy and program frameworks, including sales investigations operating procedures, any program integration, and compliance training requirements and content.
Leads, coaches, and develops multi-layer teams, including SIT managers and investigators; drive talent development, workload planning, and a culture of integrity, consistency, and continuous improvement.
Ensures consistent application of investigative outcomes, including recommendations for disciplinary actions, contract actions, agent/agency remediation, corrective action plans, and control enhancements.
Performs other duties as assigned.
Complies with all policies and standards.
Education/Experience:
Bachelor's Degree Compliance, Law, Criminal Justice or related field; or equivalent experience required
Master's Degree preferred
Juris Doctor (JD) preferred
6+ years Compliance, investigations, law enforcement leadership, SIU, FWA, audit, and/or regulatory functions within managed care, a healthcare payor, or a similarly regulated environment required
2+ years Leading people leaders and/or multi-layer teams. preferred
Experience working with Medicare Advantage sales distribution structures, including the relationships and contractual obligations among first-tier, downstream, and related entities (FDRs) required
Experience working with Medicare Advantage sales distribution models, including first-tier, downstream, and related entity (FDR) structures, captive agent employment arrangements, and independent broker/agency contracting required
Licenses/Certifications:
HCCA (CHC/CHPC), CFE, AHFI, CPCI, CPA, CIA, or other industry-related certification preferred
Pay Range: $107,700.00 - $199,300.00 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