Remote Claims Processor Jobs in Simpsonville, SC

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

• Supports effective implementation of performance improvement initiatives for capitated providers.

• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.

• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.

• Participates in provider network development and new market expansion as appropriate.

• Assists in the development and implementation of physician education with respect to clinical issues and policies.

• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

• Develops alliances with the provider community through the development and implementation of the medical management programs.

• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

• Represents the business unit at appropriate state committees and other ad hoc committees.

• May be required to work weekends and holidays in support of business operations, as needed.

Education/Experience:

• Medical Doctor or Doctor of Osteopathy.
• Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine.
• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
• Experience treating or managing care for a culturally diverse population preferred.

License/Certifications:

• Board certification by the American Board of Psychiatry and Neurology.
• Certification in Child Psychiatry, preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

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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