Manager, Payment Integrity - Readmissions
WFA Digital Insight
The demand for professionals skilled in payment integrity and fraud detection has surged, with a 25% increase in job postings over the past year. This role at Centene stands out for its focus on developing strategic plans to combat fraud, waste, and abuse. With the healthcare industry's continued shift towards remote work, professionals with expertise in medical claim investigation, compliance, and data analysis are in high demand. As the healthcare sector continues to evolve, candidates with a background in business, healthcare, or criminal justice will find this role particularly compelling. Before applying, candidates should be prepared to showcase their knowledge of medical terminology, claims processing, and data mining.
Job Description
About the Role
The Manager, Payment Integrity - Readmissions will play a pivotal role in developing and implementing strategic plans to prevent fraud, waste, and abuse. This is a critical function that requires a deep understanding of the healthcare industry, as well as the ability to analyze complex data sets and identify trends. The successful candidate will lead a team of analysts, providing guidance and oversight to ensure that all business processes and systems are operating with integrity.As a key member of the payment integrity team, the Manager will work closely with cross-functional teams to monitor and evaluate the effectiveness of current processes and systems. This will involve collaborating with stakeholders to identify areas for improvement and implementing changes to ensure compliance with state and federal regulations. The ability to communicate complex ideas and data insights to both technical and non-technical stakeholders is essential.
The role is part of a dynamic and growing organization that is committed to transforming the health of communities. With a strong focus on innovation and customer satisfaction, the company offers a collaborative and supportive work environment that encourages professional growth and development.
What You Will Do
- Develop and implement strategic plans to prevent fraud, waste, and abuse
- Lead a team of analysts, providing guidance and oversight to ensure that all business processes and systems are operating with integrity
- Monitor and evaluate the effectiveness of current processes and systems
- Collaborate with cross-functional teams to identify areas for improvement and implement changes
- Provide educational materials to identify and validate waste activities
- Respond to RFP requests and implement new policies per contractual obligation
- Attend state and federal meetings as required by specific contracts
- Prepare and present the FWA program to state and federal personnel
- Review post-payment cases with appropriate parties to obtain refunds
- Prepare and distribute monthly and quarterly savings reports
What We Are Looking For
- Bachelor's degree in Business, Healthcare, Criminal Justice, or a related field
- 4+ years of experience in medical claim investigation, compliance, or fraud and abuse
- Thorough knowledge of medical terminology
- Previous experience in a managed care environment
- Experience as a lead or supervisor of staff, including hiring, training, and managing performance
- Strong knowledge of Microsoft Excel
- Experience with data mining and analysis
- Certification in medical records or coding preferred
Nice to Have
- Experience with claims processing and medical coding
- Knowledge of state and federal regulations related to healthcare
- Experience with project management and team leadership
- Certification in a related field, such as healthcare compliance or fraud prevention
Benefits and Perks
- Competitive salary
- Comprehensive benefits package, including health insurance and 401K
- Tuition reimbursement and professional development opportunities
- Paid time off and holidays
- Flexible work arrangements, including remote and hybrid options
- Stock purchase plan and equity opportunities
- Access to cutting-edge technology and tools
- Collaborative and supportive work environment
How to Stand Out
- To stand out in your application, be sure to highlight your experience with data analysis and visualization tools, such as Excel and data mining software.
- Showcase your knowledge of medical terminology and claims processing, and be prepared to provide examples of how you have applied this knowledge in previous roles.
- Tailor your resume and cover letter to the specific requirements of the job, and be sure to include any relevant certifications or training.
- Prepare to discuss your experience with team leadership and project management, and be ready to provide examples of how you have successfully led teams and managed projects.
- Research the company and the role beforehand, and be prepared to ask informed questions during the interview process.
- Consider reaching out to current or former employees to gain insight into the company culture and work environment.
This is a remote position listed on WFA Digital, the platform for professionals who work from anywhere. Browse more remote jobs across all categories.