Manager, Payment Integrity

Centene Corporation; Missouri; Hybrid; USD 88,000 - 158,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Corporation is seeking a senior professional to develop, implement, and manage strategic fraud, waste and abuse activities across managed care programs. The role involves monitoring billing and claims processes for integrity, leading analyst teams, and crafting customized FWA plans to meet contract and federal requirements.

Responsibilities include responding to RFPs, attending state/federal meetings, presenting FWA programs during readiness reviews, and reviewing post-payment cases to

Qualifications

• Bachelor’s degree in a relevant field and 4+ years in medical claim investigation, compliance or fraud and abuse.
• Thorough knowledge of medical terminology.
• Managed care experience and staff supervision preferred.

Responsibilities

• Monitor billing and claims payment processes to assure integrity and regulatory compliance.
• Lead teams of analysts to investigate fraud, waste and abuse referrals.
• Develop customized FWA plans to meet contracts and federal requirements.
• Respond to RFPs and implement policies as required by contracts.
• Attend state/federal meetings as needed and present the FWA program during readiness reviews.
• Review post-payment cases to obtain refunds and improve controls.
• Prepare and distribute monthly and quarterly saving reports.

Skills

Leadership

Fraud investigation

Compliance

Medical terminology

Education

Bachelor’s degree in Business/Healthcare/Criminal Justice

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 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/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

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