Manager, Payment Integrity – Readmission

🕒 vor 5 Tagen

🐊 Florida, Missouri, +1 weitere Bundesländer – Remote

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

💵 $87.700 - $157.800 / Jahr

⏰ Vollzeit

🟡 Mittelstufe

🟠 Senior

👔 Manager

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Centene Corporation

WebsiteLinkedInAlle Stellen

10.000+ Mitarbeiter

Gegründet 1984

⚕️ Krankenversicherung

🤝 Non-Profit

🌍 Soziale Wirkung

Healthcare Insurance • Non-profit • Social Impact

Die Centene Corporation ist ein führender Anbieter von staatlich geförderten Gesundheitsdienstleistungen und spezialisiert sich darauf, erschwingliche und qualitativ hochwertige Gesundheitslösungen bereitzustellen. Seit über 40 Jahren konzentriert sich Centene darauf, die Gesundheit von Gemeinschaften zu verbessern, indem es den Zugang zu Medicaid-, Medicare- und Gesundheitsmarktplatz-Diensten erweitert, sowie militärische Gemeinschaften durch das TRICARE-Programm bedient. Als größte Organisation für das Management von Medicaid-Versicherungen und als wichtiger Teilnehmer am Gesundheitsmarktplatz legt Centene Wert auf lokalisierten Gesundheitsservice in Kombination mit starken Partnerschaften mit gemeinnützigen Organisationen, um die einzigartigen Bedürfnisse ihrer Mitglieder zu erfüllen. Centene engagiert sich außerdem für Unternehmensnachhaltigkeit und soziale Verantwortung, indem es Umweltbewusstsein und ethische Unternehmensführung priorisiert, um das Wohlbefinden der Gemeinschaften, denen es dient, zu verbessern.

Beschreibung

• 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.

🎯 Anforderungen

• 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.

🏖️ Vorteile

• 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