Manager, Payment Integrity - Readmissions at Centene

**Who this is for** This role is for a detail-oriented professional with a background in investigative auditing who wants to lead efforts in preventing fraud, w

Work type: remote

Location: Remote-MO | Remote-TX | Remote-FL | Remote-CA

Salary: $87,700 – $157,800/yr

Type: Full-time

Summary

**Who this is for** This role is for a detail-oriented professional with a background in investigative auditing who wants to lead efforts in preventing fraud, waste, and abuse within healthcare claims and billing. **Key highlights** You will lead a team of analysts in investigating billing discrepancies, developing fraud prevention plans, and presenting financial savings reports to state and federal agencies. **You might be a good fit if you...** - Have 4+ years of experience in medical claim investigation or compliance, with a strong grasp of medical terminology and coding. - Enjoy leading, training, and managing staff performance while maintaining high standards of billing integrity. - Are proficient in data mining and analysis, allowing you to identify trends and schemes within complex claims datasets.

Job Description

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

Monitor business processes and systems to assure integrity and compliance in billing and claims payment

Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals

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

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. Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.

License/Certification: Medical records or coding license preferred.

Pay Range: $87,700.00 - $157,800.00 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.

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