Position Purpose: Responsible for evaluating and interpreting Payment Integrity (PI) policies, Federal and State Regulatory, Contract changes to support compliant and accurate claims adjudication. Analyzes state and federal regulations, payer contractual requirements, and internal Payment Integrity program changes to determine the impact on Claims and Configuration Operations and provide feedback regarding potential operational impacts or risks from proposed changes. Partners closely with Medical Affairs, Coding, Compliance, and Claims and Configuration Operations teams to ensure policies and edits are applied accurately and consistently.
Key Details: 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.
Applicants for this job have the flexibility to work remote from home anywhere in the United States.
Benefit configuration experience preferred.
- Review Federal and State specific regulatory changes and bulletins to determine applicability to claims processing and required customizations.
- Interpret contractual provisions to ensure correct implementation of benefit, payment, and policy logic within claims workflows as well as mitigate unintended downstream consequences to provider experience or operational efficiencies.
- Evaluate policy changes for operational feasibility and claims system impact, including configuration, testing, and downstream workflows.
- Collaborate with Claims and Configuration Operations to validate interpretation of rules and ensure accuracy and consistency in adjudication outcomes.
- Collaborate with PI Leadership, Medical Affairs, Vendor partners, Compliance, and Health Plans to support pre-implementation phase.
- Develop clear policy summaries, decision documentation, and operational guidance for Claims Operations and related business units.
- Contribute to provider education content when policy changes require external communication.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience: High School Diploma or GED equivalent required. 3+ years of experience in health insurance, claims operations, payment integrity, auditing, or related discipline required.
Licenses/Certifications: CCS-Certified Coding Specialist required or RHIT - Registered Health Information Technician required or CPC - Certified Professional Coder required or Equivalent certification required.
Pay Range: $70,100.00 - $126,200.00 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.
