Director, Payment Integrity - Appeals & Disputes

Centene
Missouri, Georgia, North Carolina, Texas, Illinois, Florida
Workplace: RemoteFull timeUSD 118,400 - 219,000 annuallyFunction: Executive & General ManagementEducation: bachelorsSkills: ["Leadership","Policy development","Data analysis","Audit management","Training delivery"]

Oversee prepay waste and abuse reviews through coding, editing, and audit programs to ensure accurate, timely payments and adherence to state and federal regulations. Interpret audit results, develop action plans, and present findings to senior management while designing and implementing internal payment integrity edit and audit programs. Lead Prepay Compliance Managers to reduce waste, abuse, and fraud and deliver educational training to providers and employees to streamline compliant operations.

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Centene
Centene
3 days ago

Director, Payment Integrity - Appeals & Disputes

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Last checked: 4 hours agoStatus: Live

Job Summary

Oversee prepay waste and abuse reviews through coding, editing, and audit programs to ensure accurate, timely payments and adherence to state and federal regulations. Interpret audit results, develop action plans, and present findings to senior management while designing and implementing internal payment integrity edit and audit programs. Lead Prepay Compliance Managers to reduce waste, abuse, and fraud and deliver educational training to providers and employees to streamline compliant operations.
Location: Missouri, Georgia, North Carolina, Texas, Illinois, Florida
Workplace: Remote
Employment Type: Full time
Job Function: Executive & General Management
Seniority: Director level

Key Responsibilities

  • •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.
  • •Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures.
  • •Monitor laws and regulations impacting payment integrity policies and implement compliant changes.
  • •Direct and lead Prepay Compliance Managers and deliver educational training to providers and employees.

Pay and Benefits

Salary: USD 118,400 - 219,000 annually
Perks:Health Insurance401kEquityPaid Leave

Key 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.
  • •7+ years experience in compliance/ERM preferred.
  • •Direct and lead Prepay Compliance Managers to reduce waste, abuse, and fraud.
Experience:HealthcareClaims operationsAuditingCompliancePrepay integrity
Education:Bachelor's
Skills:LeadershipPolicy developmentData analysisAudit managementTraining delivery

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn