Carelon Integrity Manager

Anticipated End Date

Carelon Payment Integrity Manager

Carelon Payment Integrity Manager

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.
Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Carelon Payment Integrity Manager is responsible for supporting Project Raven implementation and governance, including aligning regulatory requirements with system configuration, validation activities, and operational workflows. The Compliance Manager partners with cross-functional stakeholders to ensure system logic, lookback requirements, provider exceptions, and recovery processes are compliant with state and federal requirements across multiple markets. The Compliance Manager serves as a key leader within the Carelon Insights Payment Integrity Regulatory Compliance (PIRC) organization, supporting both Project Raven and broader compliance initiatives across Medicaid and Commercial lines of business.

This role is responsible for managing foundational and strategic compliance activities that ensure regulatory adherence, operational integrity, and effective oversight of payment accuracy programs. The Compliance Manager serves as a trusted advisor within Payment Integrity, strengthening regulatory alignment and supporting continuous improvement across the organization.

• Provide strategic oversight for regulatory audits, internal audits, risk assessments, and compliance reviews across Medicaid and Commercial programs.
• Support Project Raven through validation oversight, regulatory alignment, issue tracking, and coordination between compliance, operations, IT, and data teams.
• Ensure the accuracy of claims payment through structured prevention, detection, and correction processes addressing billing, payment, and membership errors.
• Evaluate regulatory changes and health care reform updates to determine operational impact and necessary compliance actions.
• Develop and execute audit plans, conduct gap analyses, oversee audit preparedness, and coordinate evidence collection.
• Serve as a subject matter expert on applicable laws and regulations impacting Payment Integrity and fraud, waste, and abuse (FWA).
• Monitor compliance plan provisions, investigate unusual incidents, and implement corrective action plans as needed.
• Oversee key compliance tools and systems, including CONTRAXX, Doctract, Service Now (SNOW), SharePoint, and related governance platforms.
• Manage compliance mandates, project plans, milestone tracking, and leadership reporting.
• Partner with Health Plan leaders, regulators, vendors, and internal governance teams to ensure consistent adherence to compliance standards.
• Develop processes to detect systemic operational inefficiencies and mitigate regulatory risk.
• Analyze and report monthly compliance and payment integrity performance metrics.

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 an equivalent background.

• 5+ years of healthcare, regulatory, ethics, compliance, privacy, or payment integrity experience preferred; regulatory compliance experience strongly preferred.
• 2+ years of project management experience strongly preferred.
• Advanced degree (MS, MBA, JD) or professional certification (e.g., CHC, CCEP, CHPC).
• Demonstrated experience leading complex compliance programs, audits, or large-scale regulatory initiatives preferred.
• Experience…