Centene Corporation Adverse Actions Associate in Earth City, Missouri

HourlyPosition Purpose: The Adverse Actions (AA) Associate is responsible for assisting the AA team in researching network practitioners’ and Organizational Providers (OPs) medical credentialing adverse action issues for compliance with Health Net (HN), accrediting entity and regulatory standards. The Associate identifies, researches, documents and prepares adverse action findings, meeting established guidelines/standards, and presents to Medical Directors and/or Credentialing Committees for review/determination. The Associate supports national distribution of regional work and provides general administrative support to the AA team, Project Manager and/or credentialing management team.

  • Demonstrates regular, reliable and predictable attendance.

  • Requests, retrieves, reviews, analyzes and interprets primary source data (e.g., Medical Board, NPDB/HIPDB, etc.) to identify potential adverse action issues needing research and further review. All duties are performed with strict adherence to company and departmental confidentiality and protocol.

  • Monitors internal data sources and identifies, documents, processes and prepares findings for review/determination as needed.

  • Creates and maintains adverse action file documentation.

  • Contacts and works with internal (credentialing co-workers, other HN personnel, etc.) and external customers (practitioners, OPs, outside regulatory entities, etc.) to obtain, analyze document, processes, and prepare AA cases. Acts as a subject matter expert to these customers as needed.

  • Works with senior management and legal representatives, both external and internal counsel to present and provide analysis of AA cases.

  • Prepares and mails time sensitive documentation necessary for the processing of AA cases. Conducts follow-up activities as necessary and in accordance with HNI AA Classification Guidelines established by current Policies and Procedures.

  • Assists in all administrative activities and support of Peer Review and/or Credentialing Committees.

  • Composes Credentialing Committee minutes and maintains open action and monitoring log.

  • Follows-up on case/issues/finding review recommendations (e.g., requests for additional information or clarification, etc.) made by the Credentialing Committee and/or Chairperson.

  • Updates the AA data fields and/or other related fields in the Credentialing PPCS database.

  • Assists in AA and other departmental projects as assigned.

Education/Experience: Associate’s Degree in Health Care Administration or a related field preferred.

Credentialing and AA review experience a plus.

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: Adverse Actions Associate

LOCATION: Earth City, Missouri

REQNUMBER: 1098800

COMPANY: Network Development & Contracting