RN Readmission Manager, Payment Integrity

🔥 0 minutes ago

🌵 Arizona, Kansas, +3 more states – Remote

🌵 Arizona – Remote 🌪️ Kansas – Remote 🌾 Nebraska – Remote 🏰 Missouri – Remote 🎸 Tennessee – 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

• Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy • Manage a team of auditors and clinical professionals and oversee audit quality, consistency, and program performance • Oversee payer readmission review programs for accurate, compliant determinations and payment integrity objectives • Direct identification and validation of potentially preventable readmissions under MS-DRG and APR-DRG methodologies • Drive program results through audit oversight, trend analysis, standardized review criteria, and best practices • Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams • Monitor metrics, financial targets, operational benchmarks, risks, variances, and improvement opportunities • Provide operational oversight for readmission, MS-DRG, and APR-DRG review teams • Ensure compliance with regulations, managed care requirements, contracts, and internal policies • Prepare and present reports, analyses, and performance summaries to leadership and stakeholders • Identify process gaps, operational risks, and control weaknesses and implement or recommend corrective actions • Lead, coach, and develop team members • Serve as a Payment Integrity subject matter expert • Perform other duties as assigned and comply with policies and standards

🎯 Requirements

• Active Health Information Management or coding credential required, such as RHIT, RHIA, CCS, CIC, or CCDS • Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required • Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; four additional years of directly related experience may be considered in lieu of a degree • 5+ years of progressive Payment Integrity experience, including readmission review and DRG validation activities • 3+ years of people leadership experience, including direct management of teams • 2+ years of experience using Diagnosis Related Group encoder and grouper tools, such as 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, or Payment Systems Incorporated • Experience working with payer claims systems preferred • 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 • Master’s degree preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off • Holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation