Provider Reimbursement Specialist

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🔥 0 minutes ago

🗽 New York – Remote

🗽 New York – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

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.

📋 Description

• Maintains relationships with physicians, hospitals, ancillary providers and Health Net's 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 • Assists with policy and procedure interpretation • Researches, analyzes and resolves complex problems with claims development and finalization • Assists with complex claim issues and acts as the first line contact for providers on large projects • 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 • 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 • 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

🎯 Requirements

• 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 • Prefer candidates who are skilled with fee schedules and claims analysis

🏖️ 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