Manager, Payment Integrity-COB/TTL Vended Programs

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

Benefits offered by this job

Remote work options

Flexible schedule

Job summary

Centene Corporation is seeking a seasoned professional to develop, implement and manage strategic fraud, waste and abuse activities in line with state and federal requirements. The role includes leading analysts, monitoring billing integrity, and presenting the FWA program to authorities where required.

The successful candidate will have a Bachelor's degree and 4+ years in medical claim investigation or compliance, with strong knowledge of medical terminology and prior leadership experience

Qualifications

• Bachelor's degree or equivalent experience in Business, Healthcare, or Criminal Justice.
• 4+ years of medical claim investigation, compliance, or fraud and abuse experience.
• Thorough knowledge of medical terminology; prior lead/supervisor experience preferred.

Responsibilities

• Monitor billing and claims payment processes to ensure integrity and compliance.
• Lead teams of analysts to investigate all fraud, waste and abuse referrals.
• Develop education materials to identify waste activities as requested by health plan or contracts.
• Respond to RFPs and implement new policies per contractual obligations.
• Prepare and present the FWA program to state/federal personnel as needed.

Skills

Fraud investigation

Compliance

Education

Bachelor's degree in Business/Healthcare/Criminal Justice

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

Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes.

Key Responsibilities

• 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

Benefits

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.

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