Payment Integrity Policy Specialist II

🔥 0 minutes ago

🐊 Florida, Illinois, +3 more states – Remote

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

💵 $63.6k - $114.6k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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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

• Independently evaluate and interpret Payment Integrity policies, federal and state regulatory changes, contract updates, and internal program changes affecting claims adjudication and configuration operations • Analyze new and updated Payment Integrity payment policies, including pre-pay and post-pay program requirements, national guidelines, and internal PI operating models • Review federal and state regulatory changes, bulletins, and payer requirements to determine applicability to claims processing and required customizations • Interpret contractual provisions to support accurate benefit, payment, and policy logic within claims workflows • Evaluate policy changes for operational feasibility and claims system impact, including configuration, testing, production readiness, and downstream workflows • Collaborate with Claims and Configuration Operations to validate rule interpretations and support accurate, consistent adjudication outcomes • Partner with PI Leadership, Medical Affairs, Coding, Compliance, vendor partners, health plans, and related teams on end-to-end policy implementation • Develop policy summaries, decision documentation, operational guidance, and implementation notes • Contribute to provider education content when policy changes require external communication • Perform other duties as assigned and comply with all policies and standards

🎯 Requirements

• Bachelor's degree and 2–4 years of related experience, or equivalent experience acquired through applicable knowledge, duties, scope and skill • 2+ years of related experience; P2 foundation aligns to a 3+ years experience anchor in health insurance, claims operations, payment integrity, auditing, or related discipline • CCS, RHIT, CPC, or equivalent certification required • Working knowledge of healthcare claims processing, benefit/payment logic, reimbursement methodologies, payment policies, regulatory guidance, and healthcare operations • Strong analytical, problem-solving, organizational, written communication, policy documentation, and stakeholder collaboration skills • Proficiency with Microsoft Office applications • Ability to use specialized claims, policy, workflow, reporting, and configuration support systems • Experience supporting Payment Integrity policy interpretation, claims configuration, regulatory change review, pre-pay/post-pay program requirements, provider communication, audit activities, or operational readiness preferred • Knowledge of CMS, NCCI, AMA, state guidance, provider contracts, payment policies, claims editing, medical policy, compliance, quality assurance, root-cause analysis, and process improvement methods preferred • Experience with claims systems, configuration tools, policy repositories, workflow management tools, dashboards, reporting tools, or data visualization tools preferred

🏖️ 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 • Equal opportunity employer committed to diversity