Rancho Cordova, California

Position Purpose: Serve as the claims payment expert for the Plan and as a liaison between the plan, claims, and various departments to effectively identify and resolve claims issues. Act as the subject matter expert for other Claims Liaisons.

  • Analyze trends in claims processing issues and identify work process solutions
  • Lead meetings with various departments to assign claim project priorities and monitor days in step processes to ensure the projects stay on track
  • Assist in the writing work processes and continual auditing of the processes to ensure configuration, state mandates, benefits, etc.
  • Review all Medicaid Bulletins for changes and updates and submit change requests (CRs) to update payment system.
  • 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.
  • Travel and in-person provider interaction required

  • Education/Experience: High school diploma or equivalent. 5+ years of claims processing, provider billing, or provider relations experience, preferably in a managed care environment, Knowledge of provider contracts and reimbursement interpretation preferred.

    Licences/Certification: CPC certification preferred. Valid Driver’s License is required for Superior Health Plan.

    Claims Administration / Corporate: Customer service, data entry, data analysis for trending and tracking, and/or root cause analysis. The ability to disseminate information across a wide variety of audiences. The ability to prioritize work and successfully handle issue resolution in a timely manner.

    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.

    Rancho Cordova, California

    Centene Corporation, a Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on under-insured and uninsured individuals. Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans). The Company operates local health plans and offers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.

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