Senior Director, Payment Integrity - Audit Programs

📋 Description

• • Provide visionary strategic leadership for Centene Corporation's enterprise-wide Payment Integrity Audit Programs function, encompassing both prepayment and post-payment audit initiatives.
• • Spearhead the design, meticulous execution, and ongoing, iterative optimization of comprehensive audit programs aimed at significantly improving claims accuracy, drastically reducing improper payments, and robustly strengthening payment controls across all applicable lines of business.
• • Define and establish the overarching audit program roadmap, including robust governance frameworks, standardized methodologies, and clear performance benchmarks, ensuring alignment with organizational objectives and regulatory requirements.
• • Direct and manage internal audit teams and external vendor partners, fostering a collaborative and high-performance environment focused on achieving payment integrity goals.
• • Cultivate strong, cross-functional partnerships with key departments such as Claims, Clinical Operations, Finance, Compliance, Legal, Provider Relations, and Information Technology to collaboratively identify, address, and resolve complex issues, and to implement sustainable process improvements.
• • Drive the identification, prioritization, and diligent execution of audit opportunities that directly contribute to achieving critical financial and operational objectives, ensuring maximum impact and return on investment.
• • Develop, implement, and continuously monitor key performance indicators (KPIs), metrics, and comprehensive reporting mechanisms to provide clear visibility into audit program effectiveness, realized savings, and overall operational health.
• • Leverage advanced data analytics and insights to proactively identify emerging trends, potential risks, and the underlying root causes of payment errors, enabling data-driven decision-making and strategic interventions.
• • Act as a senior escalation point for the resolution of highly complex audit findings, challenging provider disputes, and intricate operational obstacles, ensuring timely and effective resolution.
• • Oversee the performance and contractual compliance of external vendors engaged in audit and recovery activities, holding them accountable for delivering high-quality services and meeting agreed-upon performance metrics.
• • Communicate audit results, identified risks, and strategic recommendations with clarity, precision, and impact to senior leadership, facilitating informed strategic planning and resource allocation.
• • Lead, mentor, and develop high-caliber audit and clinical teams, cultivating a strong culture of accountability, continuous learning, and professional growth within the Payment Integrity domain.
• • Ensure strict adherence to all company policies, procedures, and industry standards, maintaining the highest levels of integrity and compliance in all audit activities.
• • Perform other duties as assigned, demonstrating flexibility and a commitment to supporting the broader goals of the Payment Integrity department and Centene Corporation.
• • Champion a proactive approach to payment integrity, moving beyond reactive measures to implement preventative strategies and embed best practices throughout the claims adjudication lifecycle.
• • Analyze and interpret complex reimbursement methodologies, including but not limited to ICD-10-CM/PCS, MS-DRG, and APR-DRG, to ensure accurate claim adjudication and identify areas of potential overpayment or underpayment.
• • Stay abreast of evolving healthcare regulations, industry best practices, and emerging technologies in payment integrity to ensure audit programs remain current, effective, and compliant.
• • Drive innovation within audit program design and execution, exploring and implementing new technologies, analytical tools, and methodologies to enhance efficiency and effectiveness.
• • Collaborate with the Compliance department to ensure all audit activities are conducted in accordance with federal and state regulations, including HIPAA, and company policies.
• • Develop and maintain strong working relationships with external auditors, regulatory bodies, and industry peers to stay informed of best practices and potential risks.
• • Contribute to the development of the overall Payment Integrity strategy, providing expert insights and recommendations based on audit findings and market intelligence.
• • Ensure that audit findings are translated into actionable business intelligence that informs upstream process improvements and policy adjustments, thereby preventing future payment errors.
• • Manage budgets and resources effectively for the Audit Programs function, ensuring optimal allocation and utilization to achieve departmental objectives.
• • Foster a data-driven culture within the audit teams, promoting the use of analytics to guide audit selection, execution, and evaluation.
• • Oversee the development and implementation of training programs for audit staff to ensure they possess the necessary skills and knowledge to perform their roles effectively.
• • Evaluate and select appropriate technologies and vendor solutions to support audit program operations, ensuring alignment with strategic goals and return on investment.
• • Prepare and present comprehensive reports to executive leadership on the performance of audit programs, key findings, savings realized, and strategic recommendations.
• • Ensure the integrity and accuracy of all audit documentation and reporting, maintaining a high standard of evidence and audit trail.
• • Proactively identify opportunities for automation and process streamlining within audit workflows to enhance efficiency and reduce manual effort.
• • Engage with provider networks to educate them on payment integrity initiatives and to address concerns related to audit findings, fostering collaborative relationships.
• • Contribute to the development and refinement of corporate policies and procedures related to claims processing and payment integrity.