Offer summary

Qualifications:

Bachelor’s degree in a health-related field, finance, or business administration., 5+ years of experience in claims, provider relations, network development, analytics, or quality assurance., Strong written and oral communication skills, along with advanced Excel skills., Project management experience is preferred..

Key responsibilities:

Act as the liaison between the Quality and Analytics department and Provider Relations, Network, and Data Quality teams.

Identify and summarize provider issues related to claims payment and ensure quick resolution.

Research and resolve Provider Data Quality issues affecting claims payments.

Develop root cause analysis for problem resolution and ensure accurate documentation of Policies and Procedures.

Job description

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.

Position Purpose: Function as the link between the Quality and Analytics department and the following three areas: 1) Provider Relations 2) Provider Network 3) Provider Data Quality. Responsible for distilling provider issues as they relate to claims payment problems that come in through the Provider Relations teams and work with manager to ensure quick resolution. Function as the subject matter expert when questions arise related to payment terms based on specific contract terminology. Ability to dive into various different contract iterations to ensure we are paying according to the most recent contract terms.

Communicate with Provider Relations (PR) and Network staff, identify issues and trends, summarize and distill these issues into actionable reporting utilizing excel.
Research all Provider Data Quality (PDQ) issues which resulted in erroneous claims payment. Working with health plan & corporate PDQ to resolve issues using Portico and Amysis.
Function as the subject matter expert (SME) for claims issues related to configuration problems stemming from contract interpretation.
Ensure thorough, accurate and up to date Policies and Procedures (P&Ps) are documented. Review Claims and Provider Network P&Ps and suggest improvements for those P&P’s which may need updating which are hindering the efforts of the team.
Work with Claims and Quality Assurance teams to develop root cause analysis for problem resolution, working with Configuration to ensure that enacted resolution are final and non-recurring.
Run ad hoc reports using Excel, MicroStrategy, Amysis, and Portico.

Education/Experience: Bachelor’s degree in a health related field, finance, or business administration. 5+ years of combined experience in claims, provider relations, network development, analytics, or quality assurance. Experience working independently in a lead role. Possesses strong written & oral communication skills and advanced Excel skills. Project management experience preferred.

Pay Range: $68,700.00 - $123,700.00 per year

Centene 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. Total compensation may also include additional forms of incentives.

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

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