Senior Director, Payment Integrity - Audit Programs

Centene Corporation

7d•Hybrid

About The Position

Centene is seeking a Senior Director, Payment Integrity - Audit Programs to provide strategic leadership for the Audit Programs function within Payment Integrity. This role involves leading the design, execution, and continuous optimization of prepayment and post-payment audit programs to improve claims accuracy, reduce improper payments, and strengthen payment controls across all applicable lines of business. The position requires establishing the audit program roadmap, governance, methodologies, and performance standards, overseeing internal teams and external partners, and collaborating across the enterprise to implement solutions that deliver sustainable medical cost savings and operational excellence. The goal is to transform the health of communities by improving claims accuracy and payment controls.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Finance, Accounting, Business, Operations Management, or a related field required.
Candidates must hold Health Information Management or coding credentials such as RHIT, RHIA, CCS, CIC, or CCDS.
10+ years of experience in Payment Integrity, healthcare auditing, claims operations, reimbursement methodologies, or managed care operations.
5+ years experience managing prepay edits, postpay audits, or fraud, waste, and abuse programs required.
Candidates must demonstrate proficiency in ICD-10-CM/PCS, MS-DRG, and APR-DRG.
Five (5) years of progressive managerial or supervisory experience are required.

Nice To Haves

Master’s degree in Business, Healthcare Administration, Public Health, or related field preferred.
A Registered Nurse (RN) or higher qualification, in combination with a coding credential, is preferred.
3+ years experience in Medicaid and Medicare managed care plans strongly preferred.
3+ years experience implementing PI technologies (analytics, automation, vendor platforms) is a plus.
Familiarity with other review types such as Readmission, APC, and EAPG is preferred.

Responsibilities

Provide strategic leadership for enterprise payment integrity audit programs, including prepayment and post payment audits.
Design, implement, and continuously improve audit strategies, methodologies, and governance standards.
Oversee clinical, coding, pricing, and policy audit activities to reduce improper payments and improve claims accuracy.
Lead the identification, prioritization, and execution of audit opportunities aligned with financial and operational goals.
Establish performance standards, metrics, and reporting to monitor audit effectiveness, savings, and operational health.
Leverage data and analytics to identify trends, risks, and root causes of payment errors.
Partner with Claims, Clinical, Finance, Compliance, Legal, Provider Relations, and Technology teams to resolve issues and improve processes.
Serve as a senior escalation point for complex audit findings, provider disputes, and operational challenges.
Oversee external vendors supporting audit and recovery activities, ensuring quality, compliance, and performance accountability.
Communicate audit results, risks, and recommendations clearly to senior leadership.
Lead, develop, and mentor audit and clinical teams, fostering a culture of accountability and continuous improvement.
Performs other duties as assigned.
Complies with all policies and standards.