Provider Reimbursement Specialist

Centene Corporation•New York, NY

10d•$56,200 - $101,000•Remote

About The Position

Centene is transforming the health of its communities, one person at a time. As a diversified, national organization, this role offers competitive benefits and a fresh perspective on workplace flexibility. Applicants must be authorized to work in the U.S. without future employment-based visa sponsorship. This position offers the flexibility to work remotely from home, with a preference for candidates residing in New York or the tri-state area. Candidates skilled with fee schedules and claims analysis are preferred. The position's purpose is to maintain relationships with physicians, hospitals, ancillary providers, and Centene's internal Provider Network Management Department. This role acts as the first line of contact for providers and hospitals regarding claims projects and other non-routine claim issues. It oversees, in conjunction with supervisors, the resolution of project issues and communicates final resolutions to providers, hospitals, business units, and/or managers. The role also assists with policy and procedure interpretation and researches, analyzes, and resolves complex problems with claims development and finalization.

Requirements

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.
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.

Nice To Haves

Prefer candidates who are skilled with fee schedules and claims analysis.
Prefer candidates who reside in New York or within the tri-state area.

Responsibilities

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 Centene’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