Carelon Payment Integrity Manager - Kansas

About the role

The Carelon Payment Integrity Manager – Kansas is responsible for ensuring the accuracy of claims payment through the management of a robust process for prevention, detection, and correction of billing, payment, and membership errors. This role works with health plan leaders, oversees the monitoring and enforcement of the fraud, waste, and abuse compliance program to prevent and detect potential fraud, waste, and abuse activities pursuant to state and federal rules and regulations.

Responsibilities

• Coordinate and respond to inquiries from executives, ensuring timely and accurate communication.
• Handle the processing and management of Payment Integrity waivers.
• Aid in preparing responses to Requests for Proposals across all lines of business.
• Document process flows accurately to ensure clear and effective communication of processes.
• Prepare and deliver polished presentations.
• Review and approve performance guarantees, ensuring compliance with standards.
• Participate in cross-functional teams focused on problem remediation and long-term resolution.
• Evaluate regulatory compliance and Health Care Reform changes to determine potential impact.
• Evaluate provider activities to assist in the detection of fraud, waste, and abuse activities.
• Maintain oversight of the compliance plan, including fraud, waste, and abuse policies and procedures, investigate unusual incidents, and implement corrective action plans.
• Develop and analyze monthly reports.
• Create and oversee project plans, issue management, and progress reporting.
• Develop processes to support early detection of systemic issues causing operational inefficiencies.

Requirements

• Requires a BA/BS in business, engineering, nursing, finance, or healthcare administration and minimum of 5 years related work experience, including minimum of 2 years leadership experience; or any combination of education and experience, which would provide and equivalent background.

Preferred Skills, Capabilities, And Experiences

• 2-5 years of experience with Fraud, Waste and Abuse.
• Experience with payment integrity.
• Familiarity with claims systems and processes.
• Experience with GBD Facets.

Benefits

This role offers a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Pay

Details regarding pay are not specified in this posting.

Schedule

This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.