Manager, Payment Integrity Insights & Innovation

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

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work schedules (remote,hybrid

Office or field work

Job summary

Centene Corporation is hiring for a strategic role to develop, implement, and manage fraud, waste and abuse activities across health plans. You will lead teams to investigate referrals, ensure compliance with billing and claims processes, and tailor plans to meet federal requirements.

Applicants should have a bachelor’s degree in a related field and 4+ years in medical claim investigation or compliance, preferably within managed care, with strong knowledge of medical terminology and leadership

Qualifications

• 4+ years of medical claim investigation, compliance or fraud and abuse experience.
• Thorough knowledge of medical terminology.
• Experience in a managed care environment and as a lead or supervisor of staff.

Responsibilities

• Monitor billing and claims processes to ensure integrity and compliance.
• Lead analysts to investigate fraud, waste and abuse referrals.
• Develop customized fraud plans meeting contract and federal requirements.
• Create educational materials to identify waste activities as needed.
• Respond to RFPs and implement new policies per contractual obligation.
• Attend state/federal meetings as required by contracts.
• Present the FWA program to state/federal personnel during readiness reviews or go-live.

Skills

Fraud investigation

Compliance

Team leadership

Medical billing knowledge

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