Offer summary

Qualifications:

High School Diploma or equivalent; some college coursework preferred., Four years of general data management experience in an automated claims processing environment., Advanced knowledge of provider files and their relation to claims processing systems is required., Familiarity with health insurance industry regulations and certification standards is essential..

Key responsabilities:

Develop and implement business solutions through research, audit, and analysis of data.

Audit and validate pre and post payment claims for compliance with corporate policies and regulatory guidelines.

Document and report audit results, and research claims discrepancies related to provider data.

Communicate findings to management and provide data for training programs and policy improvements.

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: Develops and implements effective business solutions through research, audit, and analysis of data and/or business processes. Audits and validates routine pre and post payment claims to determine correct adjudication as well as compliance with corporate policies and procedures, and other applicable regulatory guidelines. Responsible for auditing provider data loaded into the claims processing systems, documenting and reporting audit results, and researching claims and enrollment discrepancies as they are related to provider data. In addition this position may manage a variety of other PDM related projects that typically require advanced knowledge and skills of the provider files and their relation to the claims processing systems.

Reviews and supports the claims process for medical review and cost saving initiatives.
Maintains department statistics, as necessary, for quality improvement indicators, regulatory agencies and certification bodies. Performs routine and moderately complex audits on medical review claims to identify exceptions to established claims adjudication requirements.
Researches issues from reviewed claims to determine origin and appropriate resolutions.
Summarizes findings and recommendations in reports for feedback, and distributes to management.
Communicates with claims department regarding results of audited and/or reviewed claims in order to improve claims processing and resolutions.
Provides qualified data to incorporate into training programs, policies and procedures.
Maintains current working knowledge of Health Net products, policies and procedures, contract and benefit plan coding, as well as health insurance industry and regulation and certification standards.

Education/Experience: High School Diploma or equivalent; some college coursework preferred. Four years general data management experience in an automated claims processing, claims research, or provider maintenance environment

Pay Range: $22.79 - $38.84 per hour

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

Required profile