You could be the one who changes everything for our 26 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Review high dollar claims for appropriate place of service, length of stay, match to authorization, and possible outlier DRG or Stop Loss pricing. Conduct complex business and operational analyses to assure payments are in compliance with contract; identify areas for improvement and clarification for better operational efficiency.
• Work collaboratively with various cross-functional departments to determine appropriateness of pricing• Work collaboratively with Medical Management Department to resolve any issues with medical review notes that affect high dollar claim pricing• Serve as a technical resource / coding subject matter expert for contract pricing related issues• Responsible for entire cycle of high dollar claims which includes verifying information on submitted claims, reviewing contracts, compliance guidelines, state regulations, eligibility, and authorizations to determine reimbursement, and releasing claim for payment• Identify key elements and processing requirements based on diagnosis, provider, contracts and policies and procedures utilizing broad based product or system knowledge to ensure timely payments are generated.• Conduct point of service review and resolution of high dollar claims that are pending and/or adjusted incorrectly including review, investigation, adjustment and resolution of claims, claims appeals, inquiries, and inaccuracies in payment of claims.• Collaborate with all departments to analyze complex claims issues and special claim projects which are identified through high dollar review• Review inventories to determine appropriate task to complete first and key performance indicators are met• Manage and provide testing on new product or system configuration to determine success rate of such product or configuration prior to go-live

Education/Experience: : High school diploma or equivalent and 3+ years of claims processing, medical billing, administrative, customer service, call center, physician's office or other office services experience. Previous managed care, State and/or Federal health care programs (i.e., Medicaid, Medicare) or health insurance industry experience. Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing. Licenses/Certifications: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CSS), Professional Coder-Payer (CPC-P) certification, Certified Professional Coder (CPC) or related certifications preferred.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.