Director, Clinical Payment Integrity

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
 

Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States.

Position Purpose:

• Oversee post pay/retrospective overpayment and inappropriate utilization reviews through audit programs. Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies.
• Responsibilities:
• Oversee retrospective clinical audits to ensure accurate and timely payment of claims.
• Interpret review 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 audit programs, policies, and procedures
• Monitor laws and regulations that may impact 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.
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience:

• 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

Pay Range: $116,100.00 - $214,700.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act