RN Readmission Manager, Payment Integrity

Centene Corporation

RN Readmission Manager leading Centene’s payment integrity programs for healthcare members. Overseeing readmission and DRG audits, compliance, recovery, and team performance.

Posted 8/5/2026full-timeRemote • Arizona, Kansas, Montana, New York, Tennessee • 🇺🇸 United StatesMid-LevelSenior💰 $87,700 - $157,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Payment Integrity initiatives, including readmission review and DRG validation, while effectively leading teams and ensuring compliance with healthcare regulations. Proficient in analyzing metrics and implementing best practices to drive program performance and operational improvements.

Highest-signal resume keywords

Payment Integrity LeadershipMS-DRG and APR-DRG MethodologiesHealth Information Management CredentialTeam Management and DevelopmentAudit Oversight and Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Payment IntegrityReadmission ReviewDRG ValidationTrend AnalysisOperational OversightMetrics MonitoringProcess ImprovementProject ManagementInpatient Documentation ImprovementRegulatory Compliance

Soft Skills

CollaborationCoachingCommunicationAnalytical ThinkingProblem Solving

Tools & Technologies

3M EncoderOptum EncoderTruCodeTruBridgeWebSTRATPayment Systems Incorporated

Certifications & Qualifications

RHITRHIACCSCICCCDSRegistered Nurse Licensure

Industry Keywords

Healthcare AdministrationManaged CarePayer Claims SystemsGovernment ProgramsAudit Activities

About the role

Key responsibilities & impact

Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy
Manage a team of auditors and clinical professionals and oversee audit quality, consistency, and program performance
Oversee payer readmission review programs for accurate, compliant determinations and payment integrity objectives
Direct identification and validation of potentially preventable readmissions under MS-DRG and APR-DRG methodologies
Drive program results through audit oversight, trend analysis, standardized review criteria, and best practices
Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams
Monitor metrics, financial targets, operational benchmarks, risks, variances, and improvement opportunities
Provide operational oversight for readmission, MS-DRG, and APR-DRG review teams
Ensure compliance with regulations, managed care requirements, contracts, and internal policies
Prepare and present reports, analyses, and performance summaries to leadership and stakeholders
Identify process gaps, operational risks, and control weaknesses and implement or recommend corrective actions
Lead, coach, and develop team members
Serve as a Payment Integrity subject matter expert
Perform other duties as assigned and comply with policies and standards

Requirements

What you’ll need

Active Health Information Management or coding credential required, such as RHIT, RHIA, CCS, CIC, or CCDS
Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required
Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; four additional years of directly related experience may be considered in lieu of a degree
5+ years of progressive Payment Integrity experience, including readmission review and DRG validation activities
3+ years of people leadership experience, including direct management of teams
2+ years of experience using Diagnosis Related Group encoder and grouper tools, such as 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, or Payment Systems Incorporated
Experience working with payer claims systems preferred
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
Master’s degree preferred

Benefits

Comp & perks

Competitive pay
Health insurance
401K plan
Stock purchase plans
Tuition reimbursement
Paid time off
Holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Additional forms of incentives may be included in total compensation