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: Associate's degree in Business, Healthcare Management, healthcare related field or equivalent experience. 2 years of medical billing, coding or claims processing 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.
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.