Director, Payment Integrity & Appeals (Remote)

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

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work arrangements

Job summary

Centene Corporation in North Carolina is seeking an experienced Prepay Compliance leader to oversee prepay waste and abuse reviews, edit and audit programs, and ensure payment integrity. You will guide policy design and staff through complex regulatory requirements.

The role requires a Bachelor’s degree and 7+ years in finance, auditing, or healthcare operations, with a track record in claims processes. A flexible work approach and collaboration with senior management are expected.

Qualifications

• 7+ years experience in finance, accounting, operations, or auditing.
• Experience in claims operations preferred.

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.

Education

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

Job description

Centene Corporation in North Carolina is seeking an experienced Prepay Compliance leader to oversee prepay waste and abuse reviews, edit and audit programs, and ensure payment integrity. You will guide policy design and staff through complex regulatory requirements.

The role requires a Bachelor’s degree and 7+ years in finance, auditing, or healthcare operations, with a track record in claims processes. A flexible work approach and collaboration with senior management are expected.