Manager, Payment Integrity – Platform Management

🔥 0 minutes ago

🏄 California, Florida, +2 more states – Remote

🏄 California – Remote 🐊 Florida – 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

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

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 by maintaining state and federal requirements and monitoring trends/schemes • Monitor business processes and systems to assure integrity and compliance in billing and claims payment • Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals • Develop customized fraud plans to meet contract and federal requirements • Develop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basis • Respond to RFP request and implement new policies per contractual obligation • Attend state/federal meetings as required by specific contracts • Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes • Review post-payment cases with appropriate parties to obtain refund • Prepare and distribute monthly and quarterly saving reports

🎯 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 managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred • Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred • Medical records or coding license preferred

🏖️ Benefits

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