Manager, Prepay Compliance Details

Manager, Prepay Compliance

Centene Corporation - Tampa, FL

Employment Type : Full-Time

Position Purpose:Oversee the waste, abuse and fraud prepay program. Monitor daily queue volumes, prepare executive reports, approve monthly invoice, conduct audits and maintain ROI by managing various inputs/outputs.

• Manage daily queue (Claims) volumes based on the information sent back by HealthCare Insights (HCI) to reduce waste, abuse, and fraud.
• Remain aware of Centene’s payment policies and state specific exclusions to ensure they are appropriately applied to the accept/reject recommendation made by HCI.
• Work with or train various departments on the waste, abuse and fraud prepay process to ensure all processes are followed and efficient.
• Oversee quality audits to ensure guidelines set by the state are followed including documentation in Amisys.
• Develop and maintain all policy and procedures for the new process.
• Create various reports using EDW and/or IT Reporting for monthly distribution to executives and the health plans.
• Review and approve monthly savings reports.
• Schedule and attend monthly meeting with the health plans to discuss areas of wasteful/abusive coding.
• Assist in writing provider education for correct coding according to state/federal guidelines.

Education/Experience:

Bachelor’s degree in related field or equivalent experience.

4+ years of related claims and/or nursing experience in an HMO environment.

Thorough knowledge of administrative, data management and audit functions.

Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

License/Certification:RN with current state license preferred. Certified Professional Coder (CPC) preferred.

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.