Provider Reimbursement Specialist, Fee Schedules

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🔥 0 minutes ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

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.

📋 Description

• Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' internal Provider Network Management Department • Acts as first-line contact for providers and hospitals on claims projects and other non-routine claim issues • Oversees resolution of project issues with Adjustment and New Day Unit Supervisors • Communicates final resolutions to providers, hospitals, business units and managers • Assists with policy and procedure interpretation • Researches, analyzes and resolves complex problems with claims development and finalization • Assists with complex claim issues and large projects • Manages projects with assigned adjusters and/or regional units for research, analysis and resolution • Responds directly to providers with final resolutions, including root-cause documentation, corrective action plans and process improvement initiatives • Conducts routine periodic site visits to providers, physicians and facilities • Participates with Network Management in Joint Operating Committees • Coordinates contract data corrections with Provider Network and Provider Data Management • Identifies contracting opportunities based on root-cause analysis • Interprets Health Net policies and procedures concerning claim issues, contracts and benefits • Coordinates with Provider Network Management when unable to resolve issues with providers and internal departments • Participates in process improvement activities and facilitates corrective actions • Prepares monthly reports to management documenting issues, action plans and resolutions • Researches and responds to Shared Risk Discrepancies from Participating Provider Groups • Performs other duties as assigned • Complies with all policies and standards

🎯 Requirements

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future • 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 • Experience with New York state provider fee schedules preferred • Experience with independent dispute resolution (IDR) related to the No Surprises Act preferred • Experience monitoring rate updates and changes preferred • Experience in claims analysis preferred • Candidates who reside in the Tri-state area (NY, NJ, CT, PA) are preferred

🏖️ Benefits

• Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity