RN Readmission Manager – Payment Integrity

About the role

The RN Readmission Manager, Payment Integrity will lead a team of auditors and clinical professionals to ensure accurate, compliant determinations for potentially preventable readmissions. This role supports Centene’s mission to improve health outcomes for millions of members by driving payment accuracy and cost recovery.

Key responsibilities

• Lead and oversee payment integrity initiatives focused on readmission prevention, cost recovery, and payment accuracy.
• Manage a team performing readmission, MS‑DRG, and APR‑DRG reviews, ensuring consistency and timeliness.
• Collaborate with Health Plans, Finance, Compliance, Legal, Provider Relations, and Technology teams to design and monitor readmission strategies.
• Monitor program performance against metrics, conduct trend analysis, and identify improvement opportunities.
• Ensure compliance with federal, state, and managed‑care regulations and internal policies.
• Prepare and present performance reports and analyses to senior leadership.

Required profile

• Licensed Registered Nurse with a coding credential.
• 5+ years progressive experience in payment integrity, including readmission review and DRG validation.
• 3+ years people‑leadership experience managing direct reports.
• 2+ years experience using Diagnosis Related Group encoder/grouper tools.

Required skills

• Proficiency with DRG encoder/grouper tools (e.g., 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated).
• Strong knowledge of payment integrity processes and readmission review methodologies.
• Ability to conduct audit oversight, trend analysis, and develop standardized review criteria.
• Understanding of federal and state regulatory requirements related to payment integrity.

What we offer

• Competitive benefits package.
• Flexible workplace arrangements.
• Opportunity to impact the health of 28 million members.