Manager, Payment Integrity- Readmission

Centene Corporation•Remote-TX, MO

3d•$87,700 - $157,800•Hybrid

About The Position

This position leads and oversees Payment Integrity (PI) initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy. The role involves leading a team focused on expanded readmission reviews to ensure payment accuracy and alignment with internal policies and regulatory requirements. The Manager, Payment Integrity is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions. They oversee payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives. This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies. The position is responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices. Collaboration with various internal teams (Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology) is crucial for supporting the design, execution, and monitoring of readmission and DRG-related Payment Integrity strategies. Performance monitoring against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement, is a key responsibility. The role also involves providing leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards. Ensuring compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities is essential. The position requires preparing and presenting reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations. Identifying process gaps, operational risks, and control weaknesses, and implementing or recommending corrective actions to improve quality, efficiency, and program effectiveness are also part of the role. Furthermore, the Manager will lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement. Serving as a subject matter expert for Payment Integrity practices within the assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations is expected. The role also includes performing other duties as assigned and complying with all policies and standards.

Requirements

Bachelor's degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; an additional four (4) years of directly related experience may be considered in lieu of a degree.
5 + years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
3+ years of people leadership experience, including direct management of teams, required.
2+ or more years of experience using Diagnosis Related Group encoder and grouper tools (for example, 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools), required.
Active Health Information Management or coding credentials required, such as RHIT, RHIA, CCS, CIC, or CCDS or Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required.

Nice To Haves

An RN with coding background is highly preferred.
Master’s degree preferred.
Experience working with payer claims systems preferred.
Demonstrated experience supporting government programs, regulatory compliance, or audit activities preferred.
Project management experience preferred.
Experience partnering with external vendors supporting Payment Integrity audit, recovery, or edit programs preferred.
Inpatient hospital documentation improvement experience preferred.

Responsibilities

Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy, ensuring alignment with established objectives, internal policies, and regulatory requirements.
Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.
Performs other duties as assigned.
Complies with all policies and standards.