An RN with coding background is highly preferred for this position that will lead and oversee PI initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy. You will lead a team focused on expanded readmission reviews allowing CNC to ensure payment accuracy as well as alignment with internal policies and regulatory requirements.
Position Purpose:
Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions. Oversees payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives. This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies. Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices.
- Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy, ensuring alignment with established objectives, internal policies, and regulatory requirements.
- Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
- Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
- Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
- Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
- Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
- Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
- Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
- Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
• Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; an additional four (4) years of directly related experience may be considered in lieu of a degree.
Master’s degree preferred.
- 5 + years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
- 3+ years of people leadership experience, including direct management of teams, required.
- 2+ or more years of experience using Diagnosis Related Group encoder and grouper tools (for example, 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools), required.
- Experience working with payer claims systems preferred.
- Demonstrated experience supporting government programs, regulatory compliance, or audit activities preferred.
- Project management experience preferred.
- Experience partnering with external vendors supporting Payment Integrity audit, recovery, or edit programs preferred.
- Inpatient hospital documentation improvement experience preferred.
License/Certification: Active Health Information Management or coding credentials required, such as RHIT, RHIA, CCS, CIC, or CCDS or Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required.
Pay Range: $87,700.00 - $157,800.00 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.
