Manager, Payment Integrity-COB/TTL Vended Programs

Centene Management Company LLC; Missouri; Hybrid; USD 88,000 - 158,000; Full time

Benefits offered by this job

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off

Flexible schedules

Job summary

Centene Management Company LLC is seeking a seasoned Fraud, Waste and Abuse (FWA) professional in Missouri to develop and manage strategic FWA activities across state and federal programs. You will lead analysts, monitor billing and claims processes, and ensure compliance with contracting requirements.

The role requires a bachelor’s degree and 4+ years in medical claim investigation or compliance, with experience in managed care and leadership responsibilities.

Qualifications

• 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.
• Experience in managed care environment and as a lead or supervisor of staff.
• Medical records or coding license 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.

4+ years of medical claim investigation, compliance or fraud and abuse experience.

Thorough knowledge of medical terminology

Experience in managed care environment and as a lead or supervisor of staff

Medical records or coding license preferred

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
• 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

• 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.

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.