Manager, Claims Quality Review

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November 22

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Centene Corporation

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Healthcare Insurance • Non-profit • Social Impact

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

📋 Description

• Manage the prospective review of high risk claims to ensure payment integrity and provide immediate feedback on findings including high dollar claims, coaching for quality review claims and internal audits. • Create ODS reports of known manual processing issues to increase quality and assist in increasing the overall claims knowledge to the Claims Operations team. • Manage day to day work functions of staff members to assure a smooth and timely work flow. • Manage the Claims Quality Analysts to perform quality review of completed high risk claims and provide immediate feedback to partners including coaching for Quality Review, Internal Audits and High Dollar Review. • Perform focus reviews of claims processed to identify root cause of errors and provide management with possible solutions including high dollar claims. • Build relationships and collaborate with key stakeholders to ensure timely completion of project tasks. • Provide written documentation to Claims Operations management regarding results; provide assistance to claims staff on quality issues in an effort to increase quality. • Serve as an account management contact for assigned health plans and/or specialty companies; serve as advocate to proactively address, respond to and facilitate identified customer needs and escalated issues and inquiries. • Track claims quality trends and review Internal Audit claims quality results (with a focus centered on manual errors); coordinate root cause analysis and identify corrective actions to improve results.

🎯 Requirements

• Bachelor’s degree in Healthcare Administration, Business Administration, Management Information Systems, related field, or equivalent experience. • 4+ years of related Heath insurance or claims processing experience. • Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

🏖️ Benefits

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work with remote, hybrid, field or office work schedules