Provider Reimbursement & Fee Schedules Specialist

Fidelis Care - New York; Connecticut; On-site; USD 37,000 - 67,000; Full time

Job summary

Centene is seeking a Provider Claims Specialist to maintain relationships with physicians, hospitals, and internal networks. The role handles complex claim issues, performs research and analysis, and communicates final resolutions to providers and internal teams.

You will conduct site visits, participate in Joint Operating Committees, and coordinate with Network Management for data corrections and contract opportunities.

Qualifications

• Bachelor’s degree in Health Services, Health Care/Hospital Administration, or related field.
• Minimum of two years experience in medical claims review and/or claims appeal.

Responsibilities

• Assists with complex claim issues and acts as first line contact for providers on large projects and non-routine claim issues.
• Manages projects with assigned adjusters/units for research, analysis and resolution.
• Responds with final resolution to providers, including root cause documentation and corrective action plans.
• Conducts routine site visits to providers/physicians/facilities.
• Participates with Network Management in Joint Operating Committees (JOC’s).
• Coordinates with Provider Network Management for contract data corrections.
• Identifies and reports contract issues based on root cause analysis.
• Interprets Health Net’s Policy and Procedures related to claim issues.
• Coordinates with PN Management if unresolved with providers/internal departments.
• Supports process-improvement activities and documents root causes and corrective actions.
• Prepares monthly management reports detailing issues, actions, and resolutions.

Skills

Medical claims review

Claims appeal

Root cause analysis

Provider relations

Education

Bachelor’s degree in Health Services, Health Care/Hospital Administration, a related field

Job description

Centene is seeking a Provider Claims Specialist to maintain relationships with physicians, hospitals, and internal networks. The role handles complex claim issues, performs research and analysis, and communicates final resolutions to providers and internal teams.

You will conduct site visits, participate in Joint Operating Committees, and coordinate with Network Management for data corrections and contract opportunities.