Director, Payment Integrity - Appeals & Disputes

Embedded Shishya; Deutschland; Hybrid; EUR 93.000 - 172.000; Vollzeit

Benefits dieser Stelle

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Zusammenfassung

Embedded Shishya is seeking a seasoned compliance professional to oversee prepay reviews and audit programs. You will guide policy development, ensure adherence to regulations, and manage cross‑functional teams to improve accuracy and efficiency in payments.

The role requires extensive auditing experience, strong analytical skills, and the ability to implement scalable processes. The position offers a flexible work approach with potential remote or hybrid arrangements.

Qualifikationen

• Bachelor’s degree or equivalent experience in finance, accounting, operations or auditing.
• 7+ years experience in finance, accounting, operations, or auditing; claims operations preferred.

Aufgaben

• Oversee prepay editing and retrospective audits to ensure accurate payments.
• Interpret audit results, develop action plans and present findings to senior management.
• Develop and implement continuous processes from analytic design to final report stage.
• Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures.
• Monitor applicable laws and regulations and ensure compliance with state and federal standards.
• Lead and support Prepay Compliance Managers in reducing waste, abuse and fraud.
• Deliver training programs to providers and employees to streamline operations.
• Comply with all policies and standards.

Ausbildung

Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field

Jobbeschreibung

Position Purpose

Oversee prepay waste and abuse reviews through coding, editing, and audit programs. Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies.

Responsibilities

• Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues
• Interpret audit results, develop action plans and present findings to senior management
• Develop and implement continuous processes from analytic design to final report stage
• Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures
• Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations
• Recommend process improvement to assist in developing and executing strategic initiatives and goals
• Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding
• Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience

Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience. 7+ years of finance, accounting, operations, or auditing experience. Experience in claims operations preferred.

Compliance/ERM

7+ years experience preferred

Pay Range

$107,700.00 - $199,300.00 per year

Benefits

Centene offers a comprehensive benefits package including:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

Equal Opportunity Employer

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