Director, Payment Integrity

Centene Corporation

5d

About The Position

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: Oversee prepay waste and abuse reviews through coding, editing, and audit programs. Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies. Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues Interpret audit results, develop action plans and present findings to senior management Develop and implement continuous processes from analytic design to final report stage Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations Recommend process improvement to assist in developing and executing strategic initiatives and goals Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud Performs other duties as assigned Complies with all policies and standards

Requirements

• Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience.
• 7+ years of finance, accounting, operations, or auditing experience.
• Experience in claims operations preferred.
• Compliance/ERM: 7+ years experience preferred

Responsibilities

• Oversee prepay waste and abuse reviews through coding, editing, and audit programs.
• Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies.
• Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues
• Interpret audit results, develop action plans and present findings to senior management
• Develop and implement continuous processes from analytic design to final report stage
• Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures
• Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations
• Recommend process improvement to assist in developing and executing strategic initiatives and goals
• Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding
• Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules

What This Job Offers

• Job Type: Full-time
• Career Level: Director