Provider Reimbursement Specialist

Centene Corporation•New York, NY

2d•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. 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. Applicants for this job have the flexibility to work remote from home and preferably reside in New York or within the tri-state area. 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

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.

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 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