Manager, Payment Integrity – Readmission

Centene Corporation

Manager overseeing Payment Integrity initiatives focused on readmissions and payment accuracy at a national organization serving 28 million members. Leading teams and collaborating across departments to achieve objectives.

Posted 6/2/2026full-timeRemote • Florida, Montana, Texas • 🇺🇸 United StatesMid-LevelSenior💰 $87,700 - $157,800 per yearWebsite

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Payment Integrityreadmission reviewDRG validationtrend analysisaudit oversightprocess improvementproject managementinpatient hospital documentation improvementregulatory complianceclaims systems

Soft Skills

leadershipteam managementcollaborationcommunicationcoachingaccountabilityproblem-solvinganalytical thinkingpresentation skillsquality improvement

Tools & Technologies

Diagnosis Related Group encoder3MOptum EncoderTruCodeTruBridgeWebSTRATPayment Systems Incorporatedpayer claims systemsaudit toolsdata analysis software

Certifications & Qualifications

RHITRHIACCSCICCCDSRegistered Nurse licensure

Industry Keywords

MS-DRGAPR-DRGhealthcare administrationclinical auditmanaged caregovernment programspayment integrity strategiesaudit standardscompliancefinancial targets

About the role

Key responsibilities & impact

Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions.
Oversees payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives.
This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies.
Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices.
Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.

Requirements

What you’ll need

Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; an additional four (4) years of directly related experience may be considered in lieu of a degree.
5 + years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
3+ years of people leadership experience, including direct management of teams, required.
2+ or more years of experience using Diagnosis Related Group encoder and grouper tools (for example, 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools), required.
Experience working with payer claims systems preferred.
Demonstrated experience supporting government programs, regulatory compliance, or audit activities preferred.
Project management experience preferred.
Experience partnering with external vendors supporting Payment Integrity audit, recovery, or edit programs preferred.
Inpatient hospital documentation improvement experience preferred.
Active Health Information Management or coding credentials required, such as RHIT, RHIA, CCS, CIC, or CCDS or Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required.

Benefits

Comp & perks

health insurance
401K and stock purchase plans
tuition reimbursement
paid time off plus holidays
flexible approach to work with remote, hybrid, field or office work schedules