Senior Director, Payment Integrity - Governance

📋 Description

• • Lead and oversee a comprehensive suite of payment integrity functions, encompassing a full spectrum of waste, abuse, and fraud investigations, meticulous audits, and sophisticated medical code editing scenarios. Your leadership will be instrumental in ensuring that all audit processes and coding edits strictly adhere to the intricate federal and state Medicaid medical coding and fraud/abuse guidelines, safeguarding the integrity of healthcare payments.
• • Take charge of various critical functions within the Payment Integrity department, driving accuracy and timeliness in both operational reviews and final assessments. This involves managing teams, setting performance standards, and ensuring the efficient execution of daily operations.
• • Possess the acumen to interpret complex audit results, translating data-driven insights into actionable strategies. You will collaborate closely with health plan executives, providing expert guidance and assisting them in the development and implementation of robust action plans designed to effectively address identified risks and vulnerabilities.
• • Spearhead the development and implementation of cutting-edge, continuous editing and auditing processes. This end-to-end responsibility spans from the initial analytic design phase, through the rigorous execution of audits, to the final delivery of comprehensive reports, ensuring a proactive and adaptive approach to payment integrity.
• • Identify, evaluate, and direct the implementation of new software packages and technological solutions that can enhance the efficiency, accuracy, and scope of payment integrity operations. This includes staying abreast of industry advancements and making strategic technology investments.
• • Champion compliance with all applicable state and federal regulations pertaining to waste, fraud, abuse, and medical coding. This requires a deep understanding of the regulatory landscape and the ability to translate these requirements into operational practices.
• • Develop and refine corporate policies and procedures related to payment integrity, ensuring they are clear, effective, and aligned with organizational goals. You will also be responsible for implementing corporate initiatives set forth by upper management, driving strategic alignment and execution across the department.
• • Foster strong collaborative relationships with Providers, engaging them as needed to provide essential training on payment integrity rules and regulations. This proactive engagement aims to improve understanding, reduce errors, and promote compliant practices.
• • Perform other duties as assigned, demonstrating flexibility and a willingness to contribute to the broader goals of the organization.
• • Strictly comply with all company policies and standards, upholding the highest levels of ethical conduct and operational integrity in all aspects of your role.
• • Drive strategic initiatives to enhance the overall effectiveness and efficiency of the Payment Integrity department, contributing to Centene's mission of transforming the health of communities.
• • Mentor and develop a high-performing team of payment integrity professionals, fostering a culture of continuous learning, collaboration, and accountability.
• • Represent the Payment Integrity department in cross-functional meetings and initiatives, ensuring that payment integrity considerations are integrated into broader business strategies.
• • Analyze industry trends and best practices in payment integrity to identify opportunities for innovation and improvement within Centene's operations.
• • Manage departmental budgets and resources effectively to ensure optimal allocation and return on investment.
• • Develop and maintain key performance indicators (KPIs) to measure the success and impact of payment integrity programs.
• • Ensure the timely and accurate reporting of payment integrity findings to senior leadership and relevant stakeholders.
• • Collaborate with legal and compliance teams to address complex fraud, waste, and abuse cases.
• • Oversee the development and maintenance of training materials for internal staff and external partners on payment integrity topics.
• • Contribute to the development of a robust risk management framework for payment integrity-related risks.
• • Stay informed about legislative and regulatory changes that may impact payment integrity operations and proactively adapt strategies accordingly.