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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
Posted 10 days ago
Perform quality review to ensure a high level of customer service Perform quality check and audits of inbound and outbound calls to ensure adherence to policies and procedures and high level of customer service Provide feedback on quality review to call center employees and management Identify and monitor trends and quality risks and serve as a resource regarding quality concerns or issues Collabo
Posted 11 days ago
Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Conduct investigations of potential waste, abuse, and fraud Document activity on each case and refer issues to the appropriate party Perform data mining and analysis to detec
Posted 18 days ago
Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements. Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not m
Posted 23 days ago
Provide leadership and oversight of all aspects of finance for the Business Unit Oversee all finance related activities for business unit including developing and monitoring progress against Annual Operating Plan Responsible for financial analysis, identification of month end financial drivers, and forecasting including headcount planning to ensure compliance with state requirements Responsible fo
Posted 24 days ago
Identify special needs members through the completion of health screens and other resources Work with community outreach/member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and positively impact outcomes Conduct site visits as appropriate for pr
Posted 25 days ago
The Supervisor of Claims is responsible for supervising the Claims staff who ensures the processing of member claims. The Supervisor of Claims must proactively identify issues and problems and seek means for improving the services. Experience with behavioral health or provider relations is highly desirable. Supervises the processing of claims adjudication and adjustments, production, quality and r
Posted 30 days ago
Assign new participants to the Service Coordination team following Centene policies and procedures Maintain appropriate records, files, and documentation. Distribute emails and faxes to providers Enter new and modifications to authorizations into systems Perform tasks necessary to promote participant compliance such as verifying appointments, obtaining lab results. Assess and monitor inpatient cen
Posted 1 month ago
Assist in maintaining Centene Corporation's Compliance Program; guide special projects; provide regulatory interpretation; perform compliance reporting; and develop and implement compliance auditing and monitoring strategies. Respond to external requests for information required by the organization for its regulatory filings. Respond to inquiries from state and federal regulatory agencies. Monitor
Posted 1 month ago
Provide first level remote support of customers' software and minor operating system modification requests. Investigate, research, and resolve moderately complex issues Respond to requests and document tickets in Service Now following Centene's policy and procedures Perform software installations, upgrades, and configure customer specific software Review team's current processes and recommend proc
Posted 2 months ago
Develop, edit, and maintain client and plan member facing health and wellness education materials across various digital modalities. Provide digital communications viewpoint in the planning, implementation and evaluation of communications campaigns. Develop health and wellness education content for a variety of communication mediums, ensuring materials adhere to health literacy and plain language
Posted 3 months ago
Analyze health management programs including data collection, validation and outcome measurement. May include o Financial, pharmacy, claims, provider, and member data o IRS, CMS, HHSC, HEDIS reporting o Internal data cleansing and data reconciliation analysis o Trend analysis in various functional areas of health care management. Create and generate reports through MS Excel, MS Access, and SQL usi
Posted 3 months ago
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