Position Purpose:
Ensure timely processing of complex pending medical claims. Verify and update information on the submitted claims. Review work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company practices and procedures.

• Process first time claims with added complexity.

• Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied.

• Research and determine status of medical related claims.

• Resolve claims related to adjustments, provider calls, reconsiderations and appeals.

• Communicate with stakeholders’ important information needed for the successful processing of claims with added complexity.

• Maintain appropriate records, files, documentation, etc.

• Meet and maintain department production and quality standards.

• Performs other duties as assigned.

• Complies with all policies and standards.

Education/Experience:
High school diploma or equivalent required; Associate degree or equivalent experience preferred. 2+ years of health insurance or claims related experience required. Intermediate PC and Microsoft Office skills; basic math proficiency required. Medical coding knowledge (ICD 9/10, CPT, HCPCS) and public program claims experience preferred. Experience with Medicaid, Marketplace, or Medicare claims preferred. Required to successfully complete claims basic training, COB advanced training, and ramp period.

For External Candidates: 3+ years of claims processing required. Experience with Amisys or Facets preferred. Required to successfully complete claims basic training, COB advanced training, and ramp period.

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
 

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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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