Senior Director, Payment Integrity - Governance
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 a full range of waste, abuse and/or fraud investigations, audits and medical code editing scenarios. Ensure all audits and edits adhere to federal and state Medicaid medical coding and fraud/abuse guidelines. Oversee various functions of the Payment Integrity department for accurate and timely operational reviews and final reviews Interpret audit results and assist health plan executives in the development of appropriate action plans to address identified risks Develop and implement continuous editing and auditing processes from analytic design to final report stage Identify and direct the implementation of new software packages as necessary Ensure compliance with all state and federal regulations for waste/fraud/abuse and medical coding Develop corporate policies and procedures and implement corporate initiatives set upper management Collaborate with Providers, as needed, to train on the payment integrity rules and regulations Performs other duties as assigned Complies with all policies and standards
Requirements
- Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management or related field or equivalent experience.
- 10+ years of related compliance and/or special investigation experience in managed care or CMS.
Nice To Haves
- Compliance/ERM: 10+ years of experience preferred
Responsibilities
- Oversee a full range of waste, abuse and/or fraud investigations, audits and medical code editing scenarios.
- Ensure all audits and edits adhere to federal and state Medicaid medical coding and fraud/abuse guidelines.
- Oversee various functions of the Payment Integrity department for accurate and timely operational reviews and final reviews
- Interpret audit results and assist health plan executives in the development of appropriate action plans to address identified risks
- Develop and implement continuous editing and auditing processes from analytic design to final report stage
- Identify and direct the implementation of new software packages as necessary
- Ensure compliance with all state and federal regulations for waste/fraud/abuse and medical coding
- Develop corporate policies and procedures and implement corporate initiatives set upper management
- Collaborate with Providers, as needed, to train on the payment integrity rules and regulations
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Director
