Manager, Payment Integrity

Centene Corporation; Texas; 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

Flexible work schedules (remote/hybrid

Job summary

Centene Corporation in the United States is seeking a Fraud, Waste and Abuse Leader to develop, implement and manage strategic FWA activities by maintaining state and federal requirements and monitoring trends.

You will monitor billing and claims systems for integrity, lead analysts in investigations, and develop plans to meet contractual obligations. This role offers flexible work options including remote or hybrid, with collaboration across health plans and state/federal stakeholders.

Qualifications

• Bachelor's degree in Business, Healthcare, Criminal Justice, or related field.
• 4+ years of medical claim investigation, compliance or fraud and abuse experience.
• Experience in managed care and as a lead or supervisor of staff.

Responsibilities

• Monitor billing and claims payment processes to ensure integrity and compliance.
• Lead teams of analysts to investigate fraud, waste and abuse referrals.
• Develop customized fraud plans to meet contract and federal requirements.
• Prepare monthly and quarterly saving reports and present findings.

Skills

Fraud investigation

Leadership

Compliance

Healthcare operations

Education

Bachelor's degree in Business, Healthcare, Criminal Justice, related field

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
• 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