Manager, Payment Integrity Insights & Innovation
About The Position
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. This role develops, implements, and manages strategic fraud, waste, and abuse (FWA) activities by maintaining state and federal requirements and monitoring trends/schemes. It involves monitoring business processes and systems to assure integrity and compliance in billing and claims payment, leading teams of analysts to investigate FWA referrals, and developing customized fraud plans. The role also includes developing educational materials, responding to RFPs, attending state/federal meetings, presenting the FWA program, reviewing post-payment cases, and preparing 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
- Medical records or coding license preferred.
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
- Performs other duties as assigned
- Complies with all policies and standards
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off
- holidays
- a flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Manager
