Director, Payment Integrity
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Job Description
Director overseeing payment integrity processes and compliance in the healthcare sector for Centene. Leading audit programs and training initiatives to reduce waste and fraud.
Responsibilities:
- Oversee prepay waste and abuse reviews through coding, editing, and audit programs
- Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as 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 that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations
- Recommend process improvement to assist in developing and executing strategic initiatives and goals
- Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding
- Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud
- Performs other duties as assigned
- Complies 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
- Compliance/ERM: 7+ years experience preferred
Benefits:
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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