Manager, Claims Quality Review

Centene

3d•Remote

About The Position

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. Applicants for this job have the flexibility to work remote from home anywhere in the United States. 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: Manage the prospective review of high risk claims to ensure payment integrity and provide immediate feedback on findings including high dollar claims, coaching for quality review claims and internal audits. Create ODS reports of known manual processing issues to increase quality and assist in increasing the overall claims knowledge to the Claims Operations team. Manage day to day work functions of staff members to assure a smooth and timely work flow. Manage the Claims Quality Analysts to perform quality review of completed high risk claims and provide immediate feedback to partners including coaching for Quality Review, Internal Audits and High Dollar Review. Perform focus reviews of claims processed to identify root cause of errors and provide management with possible solutions including high dollar claims. Build relationships and collaborate with key stakeholders to ensure timely completion of project tasks. Provide written documentation to Claims Operations management regarding results; provide assistance to claims staff on quality issues in an effort to increase quality. Serve as an account management contact for assigned health plans and/or specialty companies; serve as advocate to proactively address, respond to and facilitate identified customer needs and escalated issues and inquiries. Track claims quality trends and review Internal Audit claims quality results (with a focus centered on manual errors); coordinate root cause analysis and identify corrective actions to improve results.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, Management Information Systems, related field, or equivalent experience.
4+ years of related Heath insurance or claims processing experience.
Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Responsibilities

Manage the prospective review of high risk claims to ensure payment integrity and provide immediate feedback on findings including high dollar claims, coaching for quality review claims and internal audits.
Create ODS reports of known manual processing issues to increase quality and assist in increasing the overall claims knowledge to the Claims Operations team.
Manage day to day work functions of staff members to assure a smooth and timely work flow.
Manage the Claims Quality Analysts to perform quality review of completed high risk claims and provide immediate feedback to partners including coaching for Quality Review, Internal Audits and High Dollar Review.
Perform focus reviews of claims processed to identify root cause of errors and provide management with possible solutions including high dollar claims.
Build relationships and collaborate with key stakeholders to ensure timely completion of project tasks.
Provide written documentation to Claims Operations management regarding results; provide assistance to claims staff on quality issues in an effort to increase quality.
Serve as an account management contact for assigned health plans and/or specialty companies; serve as advocate to proactively address, respond to and facilitate identified customer needs and escalated issues and inquiries.
Track claims quality trends and review Internal Audit claims quality results (with a focus centered on manual errors); coordinate root cause analysis and identify corrective actions to improve results.