Manager, Payment Integrity

Centene Corporation; Kansas City (MO); Hybrid; USD 88,000 - 158,000; Full time

Job summary

Centene Corporation in Missouri is seeking a Fraud, Waste and Abuse Program Lead to develop, implement, and manage strategic FWA activities across state and federal programs. You will monitor billing integrity, lead analyst teams, and craft customized plans to meet contractual and regulatory requirements.

You'll respond to RFPs, prepare educational materials, and present the FWA program to state or federal personnel during readiness reviews and go-live transitions.

Qualifications

• 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

Responsibilities

• 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.
• Performs other duties as assigned.
• Complies with all policies and standards

Education

Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience.

Job description

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 paymentLead teams of analysts to appropriately investigate all possible fraud, waste and abuse referralsDevelop customized fraud plans to meet contract and federal requirementsDevelop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basisRespond to RFP request and implement new policies per contractual obligationAttend state/federal meetings as required by specific contractsPrepare/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 changesReview post-payment cases with appropriate parties to obtain refundPrepare and distribute monthly and quarterly saving reportsPerforms other duties as assignedComplies with all policies and standards

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

License/Certification

Medical records or coding license preferred

Pay Range

$87,700.00 - $157,800.00 per year

About the Company

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day

You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective

It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday

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