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Centene Corporation Director, Electronic Claims Payables in St. Louis, Missouri

The Director, Business Operations Claims Payables leads and manages teams responsible for the implementation and management of highly specialized and regulated processes involving Claim Payables, including cross-accumulation of member cross share across multiple claims systems, and disbursement of Explanations of Benefits (EOB’s) and Explanations of Payment (EOP’s) to members and providers, and delivery of Electronic Remittance Advices (ERA’s) to providers. The Director, Business Operations Claims Payables is considered the Process Owner of these functions.

Partners with IT development, Product Management, Health Plan Compliance and Operations, Vendor Management, Product Development, Finance and Treasury, Contact Centers, and Provider Network resources to collaboratively and rapidly deliver solutions to increase claim payables processing efficiency and compliance, reduce errors and member/provider complaints, and provide return on investment to business operations. Provide strategic oversight, governance, and controls for Claims Payables.

PositionPurpose:

  • Developand implement programs centered on quality and operations excellence

  • Developand monitor service levels to ensure compliance with state, federal, andcompany metrics and standards

  • Initiateongoing and special projects including process improvement evaluations andanalysis, department business development, ROI analysis, and annualsatisfaction initiatives

  • Directall membership related initiatives including identification of business need,strategy recommendation, project outline, management of deliverables, and ROI

  • Workcollaboratively to facilitate the design, development and implementation ofpolicies, procedures and practices related to service operations

  • Establishand maintain working relationships with external sources such as CMS forregulatory and compliance guidance

  • Developand maintain collaborative relationships with health plans, other businessunits, IT partners, and oversee training and business processes as necessaryAdditionalresponsibilities may include:

  • Leadand develop a team focused on accuracy and compliance of Electronic RemittanceAdvices (ERAs). Involves vendor management duties working with 3rd parties whodistribute multimillions of dollars of funds with associated remittanceadvices. This team is also responsible for corporate oversight and developingbest practices and process documentation for the Amisys Post-Pay System (PPS).

  • Leadand develop a team focused on imaged and printed payables documents[Explanations of Payment (EOPs) and Explanations of Benefits (EOBs)]. Partnerand manage 3rd party vendors and who distribute these documents. Must be wellversed in federal and state regulations pertaining to content, format, andavailability requirements for these documents.

  • Managea team focused on accurate and timely cross accumulation of member cost sharetoward deductible and out-of-pocket limits. Involves deep understanding ofcost-sharing benefit plan design and vendor management to accurately mergeclaims cost share from multiple vendors to a single cross-accumulationreference database used by multiple payers.

  • Maintainsknowledge of industry regulations, best practices, trends, applications, andtechnological advancements. Must be well versed in general Federal and StateClaims Regulations, as well as HIPAA Transaction & Code Set Regulations forANSI X12 EDI 835 transactions, and CAQH CORE Operating Rules for EDI 835.

Responsible for the development, implementation and management of business operations such as billing and enrollment, call center, customer service, etc. and related initiatives that impact membership for product lines and health plans. Manage service levels; identify service opportunities, new business implementations and product expansions

Experience/Experience:

Bachelor’s degree in Business or related field or equivalent experience. Masters or Advanced degree strongly preferred. 7+ years of business operations (call center, enrollment, billing, payment processing, or similar operations) experience preferably in a managed care and/or Medicare environment.

Experience working in claims payables processes at a large payer organization or in patient accounts / payment reconciliation at a large provider organization strongly preferred. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. Health insurance and project management experience preferred.

License/Certification:

EDI Certifications, Agile Certification and Lean and/or Six Sigma Black Belt strongly 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 l aw.

TITLE: Director, Electronic Claims Payables

LOCATION: St. Louis, Missouri

REQNUMBER: 1187956

COMPANY: Customer Care

POSITION TYPE: Both

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