Director, Payment Integrity - Appeals & Disputes

Centene Corporation; Illinois; Hybrid; USD 108,000 - 199,000; Full time

Benefits offered by this job

Health insurance

401(k) plan

Stock purchase plan

Tuition reimbursement

Job summary

Centene Corporation in Illinois seeks a Senior Prepay Compliance Manager to oversee prepay waste and abuse reviews, coding, editing, and audit activities to ensure timely, accurate payments and adherence to state and federal regulations.

The role leads a team, interprets audit results, and develops action plans while designing internal payment integrity programs and providing training to providers and staff.

Qualifications

• Bachelor’s degree in accounting/finance or healthcare field, with 7+ years of related experience.
• Experience in finance, accounting, operations, or auditing; claims operations preferred.
• Experience in compliance or risk management advantageous.

Responsibilities

• Oversee prepay editing and retrospective audits for accurate payments.
• Interpret audit results, develop action plans, present to senior management.
• Develop and implement continuous analytical processes from design to final report.
• Design and implement internal payment integrity edit programs and procedures.
• Monitor laws and regulations impacting payment integrity; ensure compliance.
• Recommend process improvements to support strategic initiatives.
• Develop and deliver training programs for providers and employees.
• Direct and lead Prepay Compliance Managers.
• Perform other duties as assigned.
• Complies with all policies and standards.

Skills

Prepay waste and abuse reviews

Audit programs

Regulatory compliance

Leadership

Education

Bachelor’s degree in accounting or related field

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

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.

• 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

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