Director, Payment Integrity – Appeals & Disputes

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🔥 0 minutes ago

🌽 Illinois, North Carolina, +2 more states – Remote

🌽 Illinois – Remote 🌲 North Carolina – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

💵 $118.4k - $219k / year

⏰ Full Time

🔴 Lead

👔 Director

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Oversee prepay waste and abuse reviews through coding, editing, and audit programs • Provide guidance and set policies to ensure programs adhere to state and federal regulations and company policies • Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues • Interpret audit results, develop action plans, and present findings to senior management • Develop and implement continuous processes from analytic design to final report stage • Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures • Monitor laws and regulations affecting payment integrity policies and procedures and implement compliant changes • Recommend process improvements to support strategic initiatives and goals • Develop and deliver educational training programs to providers and employees to streamline operations and ensure accurate coding • Direct and lead Prepay Compliance Managers in efforts to reduce waste, abuse, and fraud • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience • 7+ years of finance, accounting, operations, or auditing experience • Experience in claims operations preferred • 7+ years of Compliance/ERM experience preferred • Ability to ensure adherence to state and federal regulations and company policies • Experience with coding, editing, pricing, payment integrity, and audit programs • Ability to interpret audit results and develop action plans • Ability to design and implement analytic and reporting processes • Ability to develop and deliver educational training programs • Ability to lead Prepay Compliance Managers • Compliance with all policies and standards

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules