Manager, Claims Quality Review

Claims Quality Manager

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.

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa @types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Position Purpose

Manage the prospective review of high risk claims to ensure payment integrity and provide immediate feedback on findings including high dollar claims, coaching for quality review claims and internal audits. Create ODS reports of known manual processing issues to increase quality and assist in increasing the overall claims knowledge to the Claims Operations team. Manage day to day work functions of staff members to assure a smooth and timely work flow.

Manage the Claims Quality Analysts to perform quality review of completed high risk claims and provide immediate feedback to partners including coaching for Quality Review, Internal Audits and High Dollar Review.

Perform focus reviews of claims processed to identify root cause of errors and provide management with possible solutions including high dollar claims.

Build relationships and collaborate with key stakeholders to ensure timely completion of project tasks.

Provide written documentation to Claims Operations management regarding results; provide assistance to claims staff on quality issues in an effort to increase quality.

Serve as an account management contact for assigned health plans and / or specialty companies; serve as advocate to proactively address, respond to and facilitate identified customer needs and escalated issues and inquiries.

Track claims quality trends and review Internal Audit claims quality results (with a focus centered on manual errors); coordinate root cause analysis and identify corrective actions to improve results.

Education / Experience : Bachelor's degree in Healthcare Administration, Business Administration, Management Information Systems, related field, or equivalent experience. 4+ years of related Heath insurance or claims processing experience. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Pay Range : $86,000.00 - $154,700.00 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, 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