Reimbursement Specialist, Fee Schedules (Remote/Hybrid)

Fidelis Care - New York; Pennsylvania; Hybrid; USD 37,000 - 68,000; Full time

Job summary

Centene is seeking a Provider Relations / Claims Specialist to maintain relationships with physicians, hospitals, and Fidelis Care's internal networks. The role acts as first line contact for complex claims projects and non-routine issues, coordinating with adjusters and management to deliver final resolutions.

The position requires a bachelor’s in Health Services or related field and at least two years of medical claims review/appeals experience. Domestic travel and site visits are expected.

Qualifications

• Bachelor’s degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or work experience providing equivalent background required.
• Minimum of two years experience in medical claims review and/or claims appeal required.

Responsibilities

• Assists with complex claim issues and acts as the first line contact for providers on large projects and non-routine claim issues.
• Manages projects in conjunction with assigned adjusters and/or regional units for research, analysis and resolution.
• Responds directly to the providers with final resolution of the issues, up to and including: root cause documentation/feedback, necessary corrective action plans and/or process improvement initiatives.
• Conducts routine periodic site visits to providers/physicians/facilities.
• Participates with Network Management in Joint Operating Committee (JOC’s).
• Coordinates with Provider Network Management for contract data corrections.
• Identifies and reports to Provider Network Management contracting opportunities with problematic provider contracts based on root cause analysis.
• Interprets Health Net’s Policy and Procedures as it relates to claim issues, providing interpretation and clarification on contracts and benefits.
• Coordinates with Provider Network Management if unable to resolve with provider and internal departments.
• Participates in process improvement activities reporting root causes and facilitating corrective actions as needed.
• Prepares monthly reports to management to document issues, action plans, and resolutions of quality initiatives and provider relation improvement initiatives.
• Researches and responds to Shared Risk Discrepancies from Participating Provider Groups.

Skills

Claims analysis

Provider relations

Project coordination

Communication

Education

Bachelor’s degree in Health Services or related field

Job description

Centene is seeking a Provider Relations / Claims Specialist to maintain relationships with physicians, hospitals, and Fidelis Care's internal networks. The role acts as first line contact for complex claims projects and non-routine issues, coordinating with adjusters and management to deliver final resolutions.

The position requires a bachelor’s in Health Services or related field and at least two years of medical claims review/appeals experience. Domestic travel and site visits are expected.