Remote Payment Integrity Manager: Readmissions & DRG Audits

Centene Corporation; Jefferson City (MO); Hybrid; USD 88,000 - 158,000; Full time

Benefits offered by this job

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible remote/hybrid/field or office

Job summary

Centene Corporation in Missouri seeks an experienced leader to manage a team of auditors and clinicians focused on potentially preventable readmissions and payment integrity. You will oversee readmission reviews and DRG validation to ensure accurate reimbursement and compliance with policy and regulations.

You will collaborate with Health Plans, Finance, Compliance, Legal, and Technology teams, monitor metrics, and drive standard criteria and continuous improvement.

Qualifications

• Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or related field.
• 5+ years of progressive experience in Payment Integrity, including readmission review and DRG validation.
• 3+ years of people leadership experience including direct management of teams.
• 2+ years using DRG encoder/grouper tools (e.g., 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT).
• RN with coding background highly preferred; active coding credentials or nursing licensure required.

Responsibilities

• Lead and oversee Payment Integrity initiatives focused on readmissions, cost recovery, and payment accuracy.
• Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams.
• Monitor program performance using defined metrics and trend analysis.
• Provide leadership to teams performing readmission, MS-DRG, and APR-DRG reviews.
• Ensure compliance with federal/state regulations and internal policies.
• Prepare reports and present performance summaries to leadership.
• Identify gaps and implement corrective actions to improve quality and efficiency.
• Coach and develop team members to foster collaboration and continuous improvement.
• Serve as a SME for Payment Integrity practices within the assigned scope.

Skills

Leadership

Healthcare knowledge

Project management

Regulatory compliance

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 in Missouri seeks an experienced leader to manage a team of auditors and clinicians focused on potentially preventable readmissions and payment integrity. You will oversee readmission reviews and DRG validation to ensure accurate reimbursement and compliance with policy and regulations.

You will collaborate with Health Plans, Finance, Compliance, Legal, and Technology teams, monitor metrics, and drive standard criteria and continuous improvement.