Medicaid Prepayment Review Team Lead

At Commence were 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.

The Prepayment Review Team Lead manages the proactive review of high-risk claims before payment is issued serving as a critical fraud prevention mechanism. This position requires clinical expertise rapid decision-making capabilities and the ability to balance fraud prevention with provider relations. The Team Lead ensures prepayment reviews meet performance targets while maintaining appropriate medical necessity standards.

• 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

Required Qualifications

• Bachelors 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

Knowledge and Skills

• 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 timeframes while maintaining quality
• Leadership and team management skills

Other Requirements

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

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 Please note that unless you are requesting accommodation all applications must be submitted through our online application system.