Provider Reimbursement Specialist

Centene Management Company•Rego Park, NY

6d•Remote

About The Position

Centene is seeking a Provider Reimbursement Specialist to join their team. This role is crucial in transforming the health of communities by maintaining relationships with physicians, hospitals, ancillary providers, and the internal Provider Network Management Department. The specialist will serve as the primary contact for providers regarding claims projects and complex, non-routine claim issues. This position involves overseeing the resolution of project issues, communicating final resolutions, interpreting policies and procedures, and analyzing/resolving complex claims development and finalization problems. The role also includes managing projects with adjusters and regional units, conducting site visits, participating in Joint Operating Committees (JOCs), and coordinating with various departments for contract data corrections and contracting opportunities. Additionally, the specialist will prepare monthly reports on quality initiatives and provider relations, research shared risk discrepancies, and perform other assigned duties while adhering to all company policies and standards.

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.

Responsibilities

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 communicates final resolution to the provider/hospital or other business units and/or managers.
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.