RN Readmission Manager, Payment Integrity

Centene
Missouri
Workplace: RemoteFull timeUSD 87,700 - 157,800 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsEducation: bachelorsSkills: ["Leadership","Audit oversight","Quality improvement","Compliance focus","Data-driven analysis"]

Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, ensuring accurate, compliant determinations and achievement of audit quality and program performance. Manage a team of auditors and clinical professionals, drive standardized review criteria, monitor trends and metrics, and collaborate with cross-functional partners to support readmission and DRG (MS-DRG/APR-DRG) review strategies while maintaining federal/state and contractual compliance.

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FursaFursa
Centene
Centene
1 day ago

RN Readmission Manager, Payment Integrity

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Last checked: 5 hours agoStatus: Live

Job Summary

Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, ensuring accurate, compliant determinations and achievement of audit quality and program performance. Manage a team of auditors and clinical professionals, drive standardized review criteria, monitor trends and metrics, and collaborate with cross-functional partners to support readmission and DRG (MS-DRG/APR-DRG) review strategies while maintaining federal/state and contractual compliance.
Location: Missouri
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Manager level

Key Responsibilities

  • •Manage a team of auditors and clinical professionals, accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions.
  • •Oversee payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives.
  • •Drive identification and validation of potentially preventable readmissions, supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies.
  • •Monitor program performance against metrics, financial targets, and operational benchmarks using trend analysis to identify risks, variances, and improvement opportunities.
  • •Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies; provide reports and actionable recommendations to leadership.

Pay and Benefits

Salary: USD 87,700 - 157,800 annually
Perks:Health Insurance401kEquityPaid Leave

Key Requirements

  • •Licensed RN paired with an active coding credential (e.g., RHIT, RHIA, CCS, CIC, CCDS) required, or Registered Nurse licensure or higher clinical qualification in combination with a coding credential.
  • •5+ years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
  • •3+ years of people leadership experience with direct management of teams, required.
  • •2+ years of experience using Diagnosis Related Group encoder/grouper tools (e.g., 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar).
  • •Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or related field required (or additional 4 years of directly related experience in lieu of a degree).
Experience:5+ yearsHealthcarePayment integrityPayer claimsReadmission reviewDRG validationManaged care
Education:Bachelor's in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or related field
Skills:LeadershipAudit oversightQuality improvementCompliance focusData-driven analysis
Licenses:Registered Nurse (RN) licensureActive Health Information Management
Certifications:RHITRHIACCSCICCCDS
Tech Stack:Diagnosis Related Group (DRG)3M encoder/grouperOptum EncoderTruCodeTruBridgeWebSTRATPayment Systems Incorporated

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