Overview In this role you will manage partnerships between the health plan and contracted provider networks to improve member care. You will act as the primary liaison, resolve provider issues, and educate on policies, referrals, claims, and EDI. You will drive network performance in quality, cost, and utilization through consultative account management. The position offers TX-based remote work with local travel, contributing to Centene's mission to improve lives by delivering accessible, effective care.
Compensation / Benefits- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- remote, hybrid, field or office work schedules
Responsibilities- Serve as primary contact and liaison between providers and the health plan
- Triage provider issues and coordinate resolution with internal partners
- Investigate and resolve provider claim issues; communicate changes
- Initiate data entry of provider-related demographic information changes
- Educate providers on referrals, claims submission, EDI, and website usage
- Conduct provider orientations and ongoing education; update materials
- Manage network performance for assigned territory using a consultative approach
- Evaluate provider performance and develop strategic improvement plans
- Drive provider performance in risk/P4Q, HBR, HEDIS/quality, cost and utilization
- Complete special projects; travel locally 4 days/week
- Perform other duties and comply with policies
Key requirements- Bachelor's degree in related field or equivalent experience
- Two years of managed care or medical group experience (provider relations, quality improvement, claims, contracting utilization management, or clinical operations)
- Project management experience in a medical group, IPA, or health plan setting
- Proficient in HEDIS/Quality measures, cost and utilization
- Strong communication and relationship-building
- Problem solving and issue resolution
- Cross-functional collaboration
- HEDIS/Quality measures
- Cost and utilization analysis
- EDI and policies for referrals and claims submission
