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.
Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States. Start times are as early as 5:30am PT to as late as 8:30am PT.
Position Purpose: Perform regulatory claims compliance audits to support health plan operations. Completes retrospective claims audits on a monthly, quarterly and annual basis to ensure regulatory compliance.
- Perform claims compliance audits for either federal or state programs.
- Evaluate processes and performance through claim audits for scalability, effectiveness, efficiency, and risk mitigation.
- Provide written audit documentation regarding state and/or federal managed care programs and process claim audit observations.
- Review and analyze responses to claims audit observations and findings and facilitate corrective action plans.
- Facilitate compliance remediation through corrective action process.
- Identify, develop and implement corrective actions and training materials to improve program performance based on claim audit outcomes.
- Provide education and training to internal and external entities as needed on programs, compliance, and fraud, waste and abuse.
- Serve as a Claims regulatory resource related to the health plan operations and compliance audits.
- Maintain quality and productivity standards set by management.
- Adhere to communication which includes the fundamental principles of business communication of writing and grammar.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
- Bachelor's Degree in a related field such as Business, Accounting, Finance, Healthcare or equivalent experience preferred.
- 2+ years claims compliance experience, preferably with State or Federal managed care programs required.
- Understanding of claims processing rules for professional and facility claims, managed care benefits, claims adjudication concepts, claims inventory management and general claims department processes required.
- Knowledge of Medical Terminology, Current Procedural Terminology (CPT-4), Healthcare Common Procedure Coding System (HCPC), Revenue Codes and International Classification of Diseases (ICD-9/10) required.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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 Act
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