Manager, Payment Integrity Governance

Centene Corporation • St. David's, MO

1d • Hybrid

About The Position

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.

Requirements

• 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

Nice To Haves

• Previous experience in managed care environment
• Previous experience as a lead or supervisor of staff, including hiring, training, assigning work and managing performance
• Knowledge of Microsoft Excel
• Knowledge of medical coding
• Knowledge of claims processing
• Knowledge of data mining
• Medical records or coding license

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

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 5,001-10,000 employees