Payment Integrity Lead: Readmissions & DRG Compliance

Centene Corporation; Town of Texas (WI); Hybrid; USD 88,000 - 158,000; Full time

Benefits offered by this job

Competitive benefits

Flexible work arrangements

Job summary

Centene Corporation is seeking a seasoned leader to manage a team of auditors and clinical professionals responsible for payment integrity related to potentially preventable readmissions. The role focuses on DRG validation, cost recovery, and payment accuracy, with oversight of MS-DRG and APR-DRG processes and regulatory compliance.

You will lead cross-functional partnerships, monitor program performance against financial targets, and deliver actionable reports to senior leadership.

Qualifications

• Bachelor’s degree is required with additional related experience considered in lieu of degree.
• 5+ years in Payment Integrity including readmission reviews and DRG validation.
• 3+ years of people leadership experience.
• 2+ years with DRG encoder/grouper tools such as 3M/Optum/TruCode.

Responsibilities

• Lead and oversee Payment Integrity initiatives focused on readmissions, cost recovery, cost avoidance, and payment accuracy.
• Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to design and monitor readmission and DRG strategies.
• Monitor program performance against metrics, financial targets, and benchmarks; identify risks and opportunities.
• Provide leadership over readmission, MS-DRG, and APR-DRG reviews ensuring accuracy and timeliness.
• Ensure compliance with federal/state regulations and internal policies governing Payment Integrity.
• Prepare and present reports and recommendations to leadership and stakeholders.
• Identify process gaps and implement corrective actions to improve quality and efficiency.
• Coach and develop team members, fostering collaboration and continuous improvement.

Skills

Leadership

Audit & Compliance

Healthcare coding

DRG validation

Project management

Vendor collaboration

Education

Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or related field

Master’s degree preferred

Tools

3M Encoder

Optum Encoder

TruCode

TruBridge

WebSTRAT

Payment Systems Incorporated

Job description

Centene Corporation is seeking a seasoned leader to manage a team of auditors and clinical professionals responsible for payment integrity related to potentially preventable readmissions. The role focuses on DRG validation, cost recovery, and payment accuracy, with oversight of MS-DRG and APR-DRG processes and regulatory compliance.

You will lead cross-functional partnerships, monitor program performance against financial targets, and deliver actionable reports to senior leadership.