Position Purpose: Serve as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues
Audit check run and send claims to the claims department for corrections
Identify any system changes and work notify the Plan CIA Manager to ensure its implementation
Collaborate with the claims department to price pended claims correctly
Document, track and resolve all plan providers' claims projects
Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication
Identify authorization issues and trends and research for potential configuration related work process changes
Analyze trends in claims processing issues and assist in identifying and quantifying issues and reviewing work processes
Identify potential and documented eligibility issues and notify applicable departments to resolve
Research the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc.
Run claims reports regularly through provider information systems
Research verbal and written providers' claims inquiries as needed
For PA H&W only:
Facilitates the exchange of info between the Grievances, Claims processing, and Provider relations systems.
Educate contracted and non-contracted providers regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer, and available CHC-MCO resources
Communicate with providers to exchange info and to gain feedback regarding appropriate claims submission practices
Education/Experience: High school diploma or equivalent. 3 years of claims processing, provider billing, or provider relations experience, preferably in a managed care environment. Proficient in Excel, CPC certification and knowledge of provider contracts/reimbursement interpretation preferred.
For PA H&W only:
Must perform work within the state of Pennsylvania
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.