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Manager, Payment Integrity – Recovery & Accounts Receivable
Centene Corporation. Develop, implement and manage strategic fraud, waste and abuse activities while maintaining state and federal requirements and monitoring trends and schemes .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing fraud, waste, and abuse activities while ensuring compliance with state and federal regulations. Proven ability to lead recovery operations, develop staff, and implement strategic initiatives to optimize financial performance.
Highest-signal resume keywords
Fraud, Waste, And Abuse ManagementOutstanding Claims RecoveryAccounts Receivable OperationsOperational Metrics DevelopmentCross-Functional Leadership
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claim InvestigationComplianceFinancial RecoveryHealthcare CollectionsOperational And Financial KPIsInventory Aging ManagementClaims Payment IntegrityFraud Plan DevelopmentPerformance ManagementWorkload Prioritization
Soft Skills
CoachingCommunicationTeam LeadershipProblem SolvingStakeholder Engagement
Certifications & Qualifications
Certified Revenue Cycle Representative (CRCR)Certified Revenue Cycle Professional (CRCP)Certified Fraud Examiner (CFE)Accredited Health Care Fraud Investigator (AHFI)Project Management Professional (PMP)
Industry Keywords
Managed CareMedical TerminologyClaims OperationsFinancial Inventory ManagementProvider Recovery
Tech Stack
Tools & technologiesPMP
About the role
Key responsibilities & impact- Develop, implement and manage strategic fraud, waste and abuse activities while maintaining state and federal requirements and monitoring trends and schemes
- Lead Outstanding Claims Recovery and Accounts Receivable operations, with accountability for outstanding inventory, aging, collections, provider offsets/refunds, and financial recovery results
- Manage and develop staff responsible for recovery and receivable activities, including workload prioritization, performance management, coaching, and accountability for results
- Lead complex recovery and Negative Balances initiatives and large cross-functional meetings with Claims, Finance, Provider/Network Operations, Health Plans, IT, and vendors
- Establish and monitor operational metrics, controls, and reporting to identify aging or stranded balances, manage collection risk, and drive process and technology improvements
- Lead teams of analysts investigating possible fraud, waste and abuse referrals
- Monitor business processes and systems to assure integrity and compliance in billing and claims payment
- Develop customized fraud plans to meet contract and federal requirements
- Develop educational materials to identify and validate waste activities as requested by the health plan and on an ad-hoc basis
- Respond to RFP requests and implement new policies per contractual obligations
- Attend state/federal meetings as required by specific contracts
- Prepare and present the FWA program to state/federal personnel upon request, including during readiness reviews and following go-live or state agency personnel changes
- Review post-payment cases with appropriate parties to obtain refunds
- Prepare and distribute monthly and quarterly savings reports
- Perform other duties as assigned
- Comply with all policies and standards
Requirements
What you’ll need- Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience
- 4+ years of medical claim investigation, compliance or fraud and abuse experience
- Thorough knowledge of medical terminology required
- Previous experience in a managed care environment preferred
- Previous experience as a lead or supervisor of staff, including hiring, training, assigning work and managing performance, preferred
- Experience managing staff responsible for recovery inventories, receivables, collections, or claims-related financial operations preferred
- Experience managing Outstanding Claims Recovery, Accounts Receivable, healthcare collections, provider recovery, or post-payment recovery operations preferred
- Experience managing large or aging financial inventories and developing prioritization, escalation, and collection strategies preferred
- Experience developing and monitoring operational and financial KPIs, including inventory aging, recovery dollars, collections, productivity, and outstanding receivables preferred
- Experience leading large cross-functional initiatives and stakeholder meetings involving Claims, Finance, Provider/Network Operations, IT, and external vendors preferred
- Medical records or coding license preferred
- Certified Revenue Cycle Representative (CRCR), Certified Revenue Cycle Professional (CRCP), or comparable certification preferred
- Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), or comparable payment integrity certification preferred
- Project Management Professional (PMP) or comparable project/program management certification preferred
- Other certifications related to health plan claims, payment integrity, accounts receivable, collections, or recovery operations preferred
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
- Benefits may be subject to program eligibility