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Maintains relationships with healthcare providers and acts as the primary contact for complex claims projects and non-routine issues. Researches and resolves claims discrepancies while facilitating process improvement initiatives and reporting quality outcomes to management.
Requires a Bachelor's degree in Health Services, Hospital Administration, or a related field. A minimum of two years of experience in medical claims review or claims appeals is required.
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Position Purpose: Maintains relationships with physicians, hospitals, ancillary providers and Health Net's internal Provider Network Management Dept. Acts as first line contact for providers/hospitals on claims projects and other non-routine claim issues. Oversees, in conjunction with the Adjustment and New Day Unit Supervisors, resolution of project issues and is responsible to communicate final resolution to the provider/hospital or other business units and/or managers, as needed and/or as required. Assists with policy and procedure interpretation. Researches, analyzes and resolves complex problems with claims development and finalization.
Assists with complex claim issues and acts as the first line contact for providers on large projects and non-routine claim issues
Manages projects in conjunction with assigned adjusters and/or regional units for research, analysis and resolution
Responds directly to the providers with final resolution of the issues, up to and including: root cause documentation/feedback, necessary corrective action plans and/or process improvement initiatives
Conducts routine periodic site visits to providers/physicians/facilities
Participates with Network Management in Joint Operating Committee (JOC’s).
Coordinates with Provider Network and Provider Data Management for contract data corrections
Identifies and reports to Provider Network Management contracting opportunities with problematic provider contracts based on root cause analysis
Interprets Health Net’s Policy and Procedures as it relates to claim issues, providing interpretation and clarification on contracts and benefits
Coordinates with Provider Network Management (PNM) if unable to resolve with provider and internal departments
Participates in process improvement activities working directly with the process improvement team to report root causes and facilitates corrective actions as needed
Prepares monthly reports to management to document issues, action plans, and resolutions of quality initiatives and provider relation improvement initiatives
Researches and responds to Shared Risk Discrepancies from Participating Provider Groups
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: Bachelor’s degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or work experience providing equivalent background required. Minimum of two years experience in medical claims review and/or claims appeal required.
Pay Range: $56,200.00 - $101,000.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Transforming the health of the communities we serve, one person at a time.
Centene Corporation is a leading healthcare enterprise committed to helping people live healthier lives. Centene offers affordable and high-quality products to more than 1 in 15 individuals across the nation, including Medicaid and Medicare members (including Medicare Prescription Drug Plans) as well as individuals and families served by the Health Insurance Marketplace. Centene believes healthcare is best delivered locally. Our local health plans provide fully integrated, high-quality, and cost-effective services to government-sponsored and commercial healthcare programs, focusing on under-insured and uninsured individuals. Centene’s hiring practices reflect the composition of the members and communities we serve, allowing us to deliver quality, culturally sensitive healthcare to millions of members. Centene employees help change the world of healthcare and transform our communities. To learn more about career opportunities with Centene, visit: https://jobs.centene.com/
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