Centene Corporation Manager, Claims Quality in St. Louis, Missouri

Professional

Position Purpose:

Job Description Summary

Responsible for overall Quality in the Corporate Claims Operation in compliance with all regulatory and statutory requirements. Primary Functions include managing & coordinating a claims quality team responsible for inspecting Corporate Claims systems, processes and people to ensure quality outcomes. And also to track and monitor all statistical measures and behavioral indicators to evaluate root causes of quality issues.

  • Bring your Claim Quality expertise to a Fortune 100 organization that is focusing efforts on delivery of quality Claims service to our members and providers

  • Responsible for overall Quality in the Corporate Claims Operation in compliance with all regulatory and statutory requirements.

  • Primary Functions include managing & coordinating a claims quality team responsible for inspecting Corporate Claims systems, processes and people to ensure quality outcomes.

  • Track and monitor all statistical measures and behavioral indicators to evaluate Claims Analysts performance (e.g. file review, audits, reports and complaints) along with coaching and counseling employees on performance in a responsive and timely manner.

  • Implement improved methods and tools for tracking and reporting Claims quality. Methods will include data analytics and ability to create queries and ways to visualize results effectively.

  • Resolve a variety of claims quality issues through communication and interaction with other departments.

  • Respond to internal and external audits promptly and with effective explanations of findings and correction actions that will be taken to correct findings.

  • Track all quality audit activities and initiatives happening within Corporate Claims, whether internal or external.

  • Implement effective ways (internal/external) to monitor and evaluate customer concerns, issues, satisfaction and anticipate customer needs. This includes analysis of provider and member claims complaints, adjustment requests, claim rejection and denial patterns and other indicators of claim quality issues.

  • Be able to explain root causes and patterns of quality issues and steps that can be taken to correct them.

  • Drive quality initiatives intended to correct root causes of top error patterns.

  • Manage employee recruitment and development effectively.

  • Identify and implement staff development and training needs to support an effective succession plan.

  • Lead meetings in collaboration with other Claims Leaders to communicate claims quality goals, programs, and measures.

  • Maintain knowledge of current industry developments and best practices. Participate in committees and projects that will support Corporate Claims goals and objectives.

  • Perform other duties and responsibilities as assigned or required.

Education/Experience:

  • Four year degree or commensurate experience highly desirable.

  • Technical experience includes 5 to 10 years of claims processing and management.

  • Strong organizational skills required as well as the ability to multitask

  • Must be able to delegate and oversee projects and assignments to other employees as directed

  • Must know or quickly learn corporate policies, procedures and guidelines in many areas and be familiar with various functions within the company.

  • Exceptional time management and self-management skills and attributes are required to independently prioritize tasks in order to effectively meet deadlines and ensure assigned projects are completed on time and within guidelines

  • Planning and delegation (oral and written).

  • Strong communication skills are a must as well as excellent interpersonal skills and can effectively lead change.

  • Proficient in automated quality sampling and tracking systems.

  • Proficiency in Microsoft Office required including Outlook, Word, Powerpoint, and Excel; proficiency in Access desired.

  • Ability to perform SQL queries and perform complex data analysis desired.

  • Quality certification desired 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: Manager, Claims Quality

LOCATION: St. Louis, Missouri

REQNUMBER: 1112451

COMPANY: Health Insurance Operations

POSITION TYPE: Professional