Manager, Provider Reimbursement Audit

Description

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.

Position Purpose: Lead a team responsible for end-to-end Medicare, Duals, and Marketplace audit activities, including audit planning, execution, reporting, and corrective action monitoring. Manage monthly executive reporting, communicate audit results and trends to stakeholders, oversee resource allocation and team development, and drive process improvements that enhance quality, compliance, and operational effectiveness.

• Oversee various operational audits within multiple functional areas including claims, provider set up and maintenance, member eligibility, contracting, encounters, provider/member services and new business implementation. Oversee monthly claims audit management reporting.
• Manage full life cycle of claims audit reporting and upstream operational audits including business requirement gathering, creation of audit work plan and schedule, managing resources (both Operational and Claims Audit teams), managing budget, facilitation of audit execution and reporting through closure of audit period and/or operational audit.
• Effectively communicate audit results to leadership and other corporate and health plan stakeholders.
• Evaluate corporate and health plan operational processes and/or controls to identify non-compliant issues and improvement opportunities.
• Maintain audit tools to ensure that all business requirements are appropriately measured during audits.
• Coordinate cross functional corrective action plan meetings to ensure continued claims quality improvements as a result of audit findings.

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