RN Readmission Manager, Payment Integrity

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. A Licensed RN paired with a Coding Credential is the candidate this team is seeking for this position that will lead and oversee PI initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy. You will lead a team focused on expanded readmission reviews allowing CNC to ensure payment accuracy as well as alignment with internal policies and regulatory requirements. Experience Required for all RN's with Coding Credentials applying: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.Position Purpose: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.Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy, ensuring alignment with established objectives, internal policies, and regulatory requirements.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 an...