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.
NOTE: We are seeking candidates who live near Kansas City, KS for this role
Position Purpose: Acts as a liaison between Tier I providers (hospital systems, large multi-specialty groups, providers on value-based contracts and/or those with complex contracts) and the health plan. Manages Network performance for assigned territory through a consultative/account management approach. Drives provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc. Evaluates provider performance and develops strategic plan to improve performance. Performs detailed HBR analysis. Facilitates provider trainings, orientations, and coaches for performance improvement within the network and assists with claim resolution.
- Serve as a strategic partner/primary contact for Tier 1 hospital systems, multi-specialty groups, and large PCP groups with Value Based/Risk Components.
- Executes provider performance improvement strategies in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.
- Builds strong interpersonal relationships with cross functional teams both externally (provider) and internally (health plan)-C-suite Level
- Expert proficiency in tools and value-based performance (VBP) in order to educate providers resulting in improved provider performance
- Triages provider issues as needed for resolution to internal partners
- Receive and effectively respond to external provider related issues
- Investigate, resolve and communicate provider high dollar and high volume provider claim issues and changes
- Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics
- Evaluates provider performance and develops strategic plan to improve performance
- Present detailed HBR analysis and create reports for Joint Operating Committee meetings (JOC)
- Acts as a lead for the external representatives
- Coaches and trains external representatives
- Leads special projects as assigned
- Ability to travel locally 4 days a week
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience: Bachelor's degree in related field or equivalent experience. Five + years of combined provider relations, provider claims/reimbursement, or contracting experience. Knowledge of health care, managed care, Medicare or Medicaid. Bachelor's degree in healthcare or a related field preferred. Claims billing/coding knowledge preferred.
For Sunflower Health Plan: Must have prior customer service experience and insurance Claim experience with training in billing.
Pay Range: $67,400.00 - $121,300.00 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 Act