Manager, Payment Integrity – COB/TTL Vended Programs

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🔥 0 minutes ago

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

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

💵 $87.7k - $157.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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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

• Develop, implement and manage strategic fraud, waste and abuse activities while maintaining state and federal requirements and monitoring trends and schemes • Monitor business processes and systems to assure integrity and compliance in billing and claims payment • Lead teams of analysts to investigate possible fraud, waste and abuse referrals • Develop customized fraud plans to meet contract and federal requirements • Develop educational materials to identify and validate waste activities • Respond to RFP requests and implement new policies per contractual obligations • Attend state and federal meetings as required by specific contracts • Prepare and present the FWA program to state and federal personnel during readiness reviews, following go-live, or upon state agency personnel changes • Review post-payment cases with appropriate parties to obtain refunds • Prepare and distribute monthly and quarterly savings reports • Perform other duties as assigned and comply with all policies and standards

🎯 Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience • 4+ years of medical claim investigation, compliance, or fraud and abuse experience • Thorough knowledge of medical terminology required • Previous experience in a managed care environment preferred • Previous experience as a lead or supervisor of staff, including hiring, training, assigning work, and managing performance, preferred • Medical records or coding license preferred • Ability to maintain state and federal requirements and contractual obligations

🏖️ 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 • Additional forms of incentives may be included in total compensation