Position Purpose: Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' 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.

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.

Candidates experienced with New York state provider fee schedules, independent dispute resolution (IDR) related to the no surprises act, monitoring rate updates and changes, and claims analysis are preferred. Candidates who reside in the Tri-state area (NY, NJ, CT, PA) are preferred.

• 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.

Education/Experience: 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.

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