Provider Operations Consultant

Company: Centene
Location: Sacramento
Posted on: November 15, 2024

Job Description:

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.

Remote - CA

**Must reside in California

Position Purpose: Maintain collaborative relationships with physicians, hospitals, ancillary providers along with health plan and corporate teams. Act as the first line of contact for providers/hospitals on claims projects and other non-routine claim issues. Oversee and leads claim root cause and corrective actions, in conjunction with engagement and support from internal departments, and is responsible to communicate the final resolution to the external and/or internal stakeholders, as needed and/or as required. Assists with policy and procedure interpretation. Researches, analyzes and resolves complex problems with claims development and finalization, focusing on continuous process improvement. Responsible for data and business process analysis (documenting business process, gathering requirements).

• Assists large scale, cross-functional initiatives that are intended to drive performance improvement, customer satisfaction and improved compliance.
• Organizes work, drives consensus and ensures end-to-end policy/process integrity to accomplish process improvement work including identification and confirmation of participants, establishment of a strategic plan, meeting facilitation, consensus building, recommendation documentation and implementation.
• Performs detailed analysis of data, workflows, policies, procedures, skills and offers potential solutions in order to execute initiatives.
• Supports the team by utilizing industry software such as, but not limited to, Excel, PowerPoint, and Visio.
• Writes and delivers communication to all levels of organization to ensure support, awareness and effectiveness of process improvement initiatives.
• Participate with health plan in Joint Operating Committee (JOC's), on a case-by-case basis.
• Proactively coordinate with internal stakeholders for contract interpretation, data corrections, and if unable to resolve the claims issue being presented.
• Identify and report to the health plan contracting opportunities with problematic provider contracts based on research/root cause analysis.
• Ensure appropriate prioritization of work based on issue criticality and impact; escalate issues and risks through provider escalation trackers and similar mechanisms.
• Adhere to all compliance policies and protocols. Participate in regulatory activities and remediation.
• Provides other related support as needed to improve the performance of the business.
• Performs other duties as assigned.
• Complies with all policies and standards.
  Education/Experience: Bachelor's Degree in related field or equivalent experience required.
  4+ years in healthcare, insurance or other related experience required.
  Demonstrated experience and skill in process improvement, presenting and facilitating required.
  Pay Range: $54,000.00 - $97,100.00 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

Keywords: Centene, San Bruno , Provider Operations Consultant, Professions , Sacramento, California