Manager, Payment Integrity – Readmission

🕒 il y a 9 jours

🐊 Florida, Missouri, +1 états de plus – Distant

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

💵 $87 700 - $157 800 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

👔 Manager

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Centene Corporation

Site WebLinkedInTous les Emplois

10 000+ employés

Fondée en 1984

⚕️ Assurance santé

🤝 À but non lucratif

🌍 Impact social

Healthcare Insurance • Non-profit • Social Impact

La société Centene Corporation est un leader dans la fourniture de services de santé subventionnés par le gouvernement, spécialisée dans la délivrance de solutions de santé abordables et de haute qualité. Depuis plus de 40 ans, Centene s’est concentrée sur la transformation de la santé des communautés en élargissant l'accès aux services de Medicaid, Medicare, et au marché de l'assurance santé, tout en servant les communautés militaires à travers le programme TRICARE. En tant que plus grande organisation de gestion des soins Medicaid et un acteur clé du marché, Centene met l'accent sur une prestation de soins de santé localisée combinée à des partenariats solides avec des organisations à but non lucratif pour répondre aux besoins uniques de ses membres. Centene s’engage également pour le développement durable et la responsabilité sociale des entreprises, en privilégiant la gestion environnementale et la gouvernance éthique afin d'améliorer le bien-être des communautés qu’elle dessert.

Description

• 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.

🎯 Exigences

• 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.

🏖️ Avantages

• 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