Healthcare Network Specialist at Sunshine State Health Plan

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.

* Qualified candidates must reside in Florida (preferably in Miami Dade county) ​* This role will cover portions of South Miami.

Position Purpose:

• Serve as primary contact for providers and act as a liaison between the providers and the health plan

• Triages provider issues as needed for resolution to internal partners

• Receive and effectively respond to external provider related issues

• Investigate, resolve and communicate provider claim issues and changes

• Initiate data entry of provider-related demographic information changes

• Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics

• Perform provider orientations and ongoing provider education, including writing and updating orientation materials

• Manages Network performance for assigned territory through a consultative/account management approach

• Evaluates provider performance and develops strategic plan to improve performance

• Drives provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.

• Completes special projects as assigned

• Ability to travel locally 4 days a week
• Performs other duties as assigned

• Complies with all policies and standards

Acts as a liaison between Tier III and Tier IV providers (small to medium PCP groups not on risk contracts and providers with upside only incentives) and the health plan. Manages Network performance for assigned territory through a consultative/account management approach. Drives provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc. Evaluates provider performance and develops strategic plan to improve performance. Performs detailed HBR analysis. Facilitates provider trainings, orientations, and coaches for performance improvement within the network and assists with claim resolution.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 0-2 years of provider relations, provider claims/reimbursement, or contracting experience. Knowledge of health care, managed care, Medicare or Medicaid. Bachelor’s degree in healthcare or a related field preferred. Claims billing/coding knowledge preferred.

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. Total compensation may also include additional forms of incentives.

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