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.

Key Details: 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

• 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.

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