Provider Operations Consultant

at  Centene

You could be the one who changes everything for our 28 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: Maintain collaborative relationships with physicians, hospitals, ancillary providers along with health plan and corporate teams. Act as the first line of contact for providers/hospitals on claims projects and other non-routine claim issues. Oversee and leads claim root cause and corrective actions, in conjunction with engagement and support from internal departments, and is responsible to communicate the final resolution to the external and/or internal stakeholders, as needed and/or as required. Assists with policy and procedure interpretation. Researches, analyzes and resolves complex problems with claims development and finalization, focusing on continuous process improvement. Responsible for data and business process analysis (documenting business process, gathering requirements).

• Remote - California but will have to go into the office in Woodland Hills or Sacramento once a quarter
• Positively engage and collaborate with key stakeholders while anticipating potential provider conflicts; and identify, communicate, and act on proactive solutions
• Manage and coordinate projects in conjunction with external and internal stakeholders for research, analysis, and resolution
• Respond directly to the providers/hospitals with final resolution of the issues raised, up to and including leading root cause and necessary corrective action plans and/or process improvement initiatives
• Assist with complex claim issues and act as the first point of contact for providers/hospitals on large projects and non-routine claim issues
• Participate with health plan in Joint Operating Committee (JOC’s), on a case-by-case basis
• Proactively coordinate with internal stakeholders for contract interpretation, data corrections, and if unable to resolve the claims issue being presented
• Identify and report to the health plan contracting opportunities with problematic provider contracts based on research/root cause analysis
• Interpret and offer process improvement solutions on health plan policy and procedures as it relates to claim issues
• Translate technical claims issues into executive level presentations
• Participate and lead process improvement activities in partnership with internal stakeholders to report root cause and facilitate corrective actions as needed
• Ensure appropriate prioritization of work based on issue criticality and impact; escalate issues and risks through provider escalation trackers and similar mechanisms
• Adhere to all compliance policies and protocols
• Participate in regulatory activities and remediation
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Bachelor’s Degree in Health Services, Health Care/Hospital Administration, a related field or any or equivalent work experience required. 2+ years in medical claims review and/or claims appeals required. Experience in AVS and Amisys is highly preferred.
Pay Range: $54,000.00 - $97,100.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Ac

• Remote - California but will have to go into the office in Woodland Hills or Sacramento once a quarter
• Positively engage and collaborate with key stakeholders while anticipating potential provider conflicts; and identify, communicate, and act on proactive solutions
• Manage and coordinate projects in conjunction with external and internal stakeholders for research, analysis, and resolution
• Respond directly to the providers/hospitals with final resolution of the issues raised, up to and including leading root cause and necessary corrective action plans and/or process improvement initiatives
• Assist with complex claim issues and act as the first point of contact for providers/hospitals on large projects and non-routine claim issues
• Participate with health plan in Joint Operating Committee (JOC’s), on a case-by-case basis
• Proactively coordinate with internal stakeholders for contract interpretation, data corrections, and if unable to resolve the claims issue being presented
• Identify and report to the health plan contracting opportunities with problematic provider contracts based on research/root cause analysis
• Interpret and offer process improvement solutions on health plan policy and procedures as it relates to claim issues
• Translate technical claims issues into executive level presentations
• Participate and lead process improvement activities in partnership with internal stakeholders to report root cause and facilitate corrective actions as needed
• Ensure appropriate prioritization of work based on issue criticality and impact; escalate issues and risks through provider escalation trackers and similar mechanisms
• Adhere to all compliance policies and protocols
• Participate in regulatory activities and remediation
• Performs other duties as assigned
• Complies with all policies and standard