Medicaid Prepayment Review Team Lead

Overview

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data.

We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

Job Type: Full-time

• Oversee prepayment review operations and staff
• Develop and refine prepayment review criteria and triggers
• Review high-risk claims before payment authorization
• Request and evaluate supporting documentation from providers
• Coordinate clinical reviews with nurses and medical professionals
• Make determination on claim approval, denial, or adjustment
• Document rationale for all prepayment decisions
• Manage provider appeals of prepayment denials
• Monitor prepayment review turnaround times and accuracy
• Track savings from prevented improper payments
• Collaborate with provider education team on common billing errors
• Participate in quarterly business planning and fraud trend identification

• Bachelor s degree in Nursing, Healthcare Administration, or related field
• Clinical license (RN or higher) preferred
• Healthcare coding certification (CPC, CCS) strongly preferred
• Minimum 5 years of experience in utilization review, medical necessity determination, or similar role
• Minimum 3 years of supervisory experience in healthcare operations
• Experience with Medicaid prior authorization or claims review processes
• Experience managing high-volume review operations

• Strong clinical knowledge and medical necessity expertise
• Understanding of Medicaid coverage policies and billing requirements
• Proficiency with medical coding and documentation standards
• Knowledge of common fraud schemes in prepayment environment
• Excellent judgment and decision-making capabilities
• Strong attention to detail and accuracy
• Ability to work under tight time frames while maintaining quality
• Leadership and team management skills

• Full-time dedication to Indiana contract
• Available for meetings at State offices as required
• Successfully pass background check
• Subject to State approval

Commence.

AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at  or hr. Please note that unless you are requesting accommodation, all applications must be submitted through our online application system.