Senior Provider Operations Auditor

Centene Corporation

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.

Position Purpose Drives market compliance regarding terminations in response to requirements of CMS and AHCA. Participates in market operational audits, and coordinates all operational audit related activities across various functional areas in support of operational goals. Provides ongoing coordination, analysis, and communication of operational compliance to all of the market operations. Supports the process to maintain the integrity of provider network data by reconciling discrepancies within existing data and presented in provider network reports sent to the state agency. Completes online research and/or conducts phone, email, or fax validations to coordinate the updating of source systems with accurate information.

• Hosts regular meetings with Compliance to ensure that the market is aligned with regulatory requirements.
• Researches, understands, problem solves and reports root cause of metric variances, and proposes possible business solutions in reports submitted regularly to the state/regional agency.
• Collaborates with shared services departments to include, but not limited to, enrollment and IT, to identify systemic breakdowns in the processes.
• Ensures engagement in making system changes and identifies opportunities to improve efficiency through automation.
• Drives all essential process improvement for terminations and presenting improvements to management and senior leadership.
• Serves as a subject matter expert regarding all process flows including understanding systems used and functions performed within each work type, dependencies/interactions and identification of potential impact resulting from changes.
• Develops and maintains interdepartmental relationships to ensure proper involvement, cooperation and communication of changes are executed appropriately.
• Assists with audit reviews of reports submitted to the state/regional agency for accuracy, and provides timely feedback on findings. Type of audits include PCP load demographics, all newly added/updated provider loads, hospital and facility state-wide rates, regulatory research to ensure payment rule compliance and validation on all market specifics or CMS rate update fee schedules.
• Communicates clearly, both written and verbal, and follows up with various areas to ensure tasks are completed or issues are escalated appropriately.
• Performs quality checks throughout the directory process to ensure accuracy in the data and reporting.
• Assists in the development and maintenance of various policies and procedures affecting the operations of the department.
• Provides ongoing operational analysis of process components, while identifying and implementing changes as necessary to improve the level of quality and efficiency as measured by key performance indicators.
• Performs special projects as assigned.

Candidate Education A High School or GED. A Bachelor's Degree in a related field is preferred. 5+ years of experience in operational support, operational auditing or provider/network development administration support is required. 3+ years of experience in managed care is required.

Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.

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