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Position Purpose:
Perform review and audit of high dollar claims. Perform coding research. Conduct complex business and operational analyses to assure payments are in compliance with contract; identify areas for improvement and clarification for better operational efficiency resulting in better initiative, contract, and benefit implementation as well as better maintenance long term.
Serve as the contract review and claims pricing expert for the Plan and as a liaison between various internal departments to effectively identify and resolve high dollar claims issues
Audit high dollar claims to identify areas of improvement
Perform complex tracking, trending, and analyses of errors in structured excel spreadsheets and/or databases
Analyze trends in pricing issues, identify and quantify issues and implement changes to work processes
Collaborate with all departments to analyze complex claims issues and special claim projects
Verify information on submitted claims, reviewing contracts, eligibility, and authorizations to determine reimbursement, and ensuring payment instructions are sent to claims department for claims payment
Identify key elements and processing requirements based on diagnosis, provider, contracts and policies and procedures utilizing broad based product or system knowledge to ensure timely payments are generated
Conduct point of service review and resolution of high dollar claims that are pending and/or adjusted incorrectly including review, investigation, adjustment and resolution of claims, claims appeals, inquiries, and inaccuracies in payment of claims
Collaborate with all departments to analyze complex claims issues and special claim projects
Education/Experience:
Associate’s degree in Business, Healthcare Management, related field or equivalent experience. Certified Professional Coder (CPC) or related certifications preferred. 3+ years of combined managed care or State and/or Federal health care programs experience (i.e., Medicaid, Medicare) in health insurance industry. 4+ years of medical billing or physician’s office experience. Working knowledge of coding and billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting, claims processing, and provider customer service/relations.
License/Certification:
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CSS), Professional Coder-Payer (CPC-P) certification, Certified Professional Coder (CPC) or related certifications preferred. 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. TITLE: Coding Analyst II LOCATION: Tampa, Florida REQNUMBER: 1213125 COMPANY: Administrative & Operations support POSITION TYPE: Both