Manager, Payment Integrity – Readmission

🕒 Junho 2

🐊 Florida, Missouri, +1 estados a mais – Remoto

🐊 Florida – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

💵 $87.700 - $157.800 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

👻 Score fantasma 35%

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Centene Corporation

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1984

🛡️ Seguros

💼 Consultoria

🏥 Saúde

Insurance • Consulting • Healthcare

Centene Corporation é uma provedora líder de serviços de saúde patrocinados pelo governo, especializada em oferecer soluções de saúde acessíveis e de alta qualidade. Há mais de 40 anos, a Centene tem se dedicado a transformar a saúde das comunidades, ampliando o acesso a Medicaid, Medicare e ao Health Insurance Marketplace, além de atender comunidades militares por meio do programa TRICARE. Como a maior organização de managed care do Medicaid e participante-chave no Marketplace, a Centene enfatiza a entrega de cuidados de saúde com foco local, combinada a parcerias sólidas com organizações sem fins lucrativos para atender às necessidades únicas de seus membros. A Centene também é comprometida com sustentabilidade corporativa e responsabilidade social, priorizando a gestão ambiental e a governança ética para promover o bem-estar das comunidades que atende.

Descrição

• Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions. • Oversees 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. • Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices. • 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.

🎯 Requisitos

• 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. • 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. • 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.

🏖️ Benefícios

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