Description
Position Purpose: The Payment Integrity Policy Specialist II supports payment accuracy, compliance, and cost-containment objectives by independently evaluating and interpreting Payment Integrity policies, federal and state regulatory changes, contract updates, and internal program changes that impact claims adjudication and configuration operations. This role partners with Medical Affairs, Coding, Compliance, Claims, Configuration Operations, vendors, health plans, and other stakeholders to ensure policy logic, edits, and operational guidance are applied accurately and consistently.- Analyze new and updated Payment Integrity payment policies, including pre-pay and post-pay program requirements, national guidelines, and internal PI operating models.
- Review federal and state regulatory changes, bulletins, and payer requirements to determine applicability to claims processing and required customizations.
- Interpret contractual provisions to support accurate benefit, payment, and policy logic within claims workflows while helping mitigate provider experience or operational efficiency impacts.
- Evaluate policy changes for operational feasibility and claims system impact, including configuration, testing, production readiness, and downstream workflows.
- Collaborate with Claims and Configuration Operations to validate interpretation of rules and support accurate and consistent adjudication outcomes.
- Partner with PI Leadership, Medical Affairs, Coding, Compliance, vendor partners, health plans, and related teams to support end-to-end policy implementation.
- Develop clear policy summaries, decision documentation, operational guidance, and implementation notes for Claims Operations and related business units.
- Contribute to provider education content when policy changes require external communication.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience: Requires a Bachelor's degree and 2 – 4 years of related experience, or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
2+ years related experience; P2 foundation aligns to current Claims Policy Analyst experience anchor of 3+ years in health insurance, claims operations, payment integrity, auditing, or related discipline required.
Working knowledge of healthcare claims processing, benefit/payment logic, reimbursement methodologies, payment policies, regulatory guidance, and healthcare operations required.
Strong analytical, problem-solving, organizational, written communication, policy documentation, and stakeholder collaboration skills required.
Proficiency with Microsoft Office applications and ability to use specialized claims, policy, workflow, reporting, and configuration support systems required.
Experience supporting Payment Integrity policy interpretation, claims configuration, regulatory change review, pre-pay/post-pay program requirements, provider communication, audit activities, or operational readiness preferred.
Knowledge of CMS, NCCI, AMA, state guidance, provider contracts, payment policies, claims editing, medical policy, compliance, quality assurance, root-cause analysis, and process improvement methods preferred.
Experience with claims systems, configuration tools, policy repositories, workflow management tools, dashboards, reporting tools, or data visualization tools preferred.
License/Certification:
- CCS, RHIT, CPC, or equivalent certification required
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
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
