Director, Payment Integrity - Edit Programs

Centene Management Company LLC; United States; Hybrid; USD 118,000 - 219,000; Full time

Benefits offered by this job

Health Insurance

401K & stock plans

Tuition reimbursement

Paid time off

Flexible work schedules

Job summary

Centene Management Company LLC in the United States is hiring for a Senior Prepay Compliance Manager to oversee waste and abuse reviews and ensure accurate coding and payments.

You will develop and implement policies, lead internal teams, and deliver training to providers and employees to streamline processes while complying with state and federal regulations. Flexible remote/hybrid options are available and total compensation reflects market standards.

Qualifications

• Bachelor's degree as required or equivalent experience.
• 7+ years of finance, accounting, operations or auditing experience.
• Experience in claims operations preferred.

Responsibilities

• Oversee prepay waste and abuse reviews through coding, editing, and audit programs.
• Provide guidance and set policies to ensure program compliance with regulations and policy.
• Oversee prepay editing and retrospective audits to ensure accurate payments.
• Interpret audit results and present findings to senior management.
• Develop and implement continuous processes from analytic design to final report.
• Design and implement internal payment integrity edit and audit programs, policies and procedures.
• Monitor laws and regulations impacting payment integrity and update policies.
• Lead Prepay Compliance Managers to reduce waste, abuse, and fraud.
• Complies with policies and standards.

Skills

Audit

Policy development

Training delivery

Finance knowledge

Education

Bachelor's degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, 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

• Pay Range: $118,400.00 - $219,000.00 per year

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules

Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Equal Opportunity Employment

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.

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.