Provider Reimbursement Specialist, Fee Schedules

Centene Corporation

. Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' internal Provider Network Management Department .

Posted 9/21/2026full-timeRemote • United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claims review and resolution, with a strong focus on provider relations and process improvement initiatives. Proficient in analyzing complex claims issues and implementing corrective action plans in compliance with health policies.

Highest-signal resume keywords

Medical Claims ReviewClaims AnalysisProvider Relations ManagementProcess Improvement InitiativesIndependent Dispute Resolution (IDR)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims DevelopmentClaims FinalizationRoot-Cause AnalysisPolicy InterpretationContract Data CorrectionsRate MonitoringNew York State Provider Fee SchedulesCorrective Action PlansProject ManagementComplex Problem Resolution

Soft Skills

CommunicationInterpersonal SkillsAnalytical ThinkingCollaborationProblem-Solving

Industry Keywords

Health ServicesHealth Care AdministrationNo Surprises ActParticipating Provider GroupsJoint Operating Committees

About the role

Key responsibilities & impact

Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' internal Provider Network Management Department
Acts as first-line contact for providers and hospitals on claims projects and other non-routine claim issues
Oversees resolution of project issues with Adjustment and New Day Unit Supervisors
Communicates final resolutions to providers, hospitals, business units and managers
Assists with policy and procedure interpretation
Researches, analyzes and resolves complex problems with claims development and finalization
Assists with complex claim issues and large projects
Manages projects with assigned adjusters and/or regional units for research, analysis and resolution
Responds directly to providers with final resolutions, including root-cause documentation, corrective action plans and process improvement initiatives
Conducts routine periodic site visits to providers, physicians and facilities
Participates with Network Management in Joint Operating Committees
Coordinates contract data corrections with Provider Network and Provider Data Management
Identifies contracting opportunities based on root-cause analysis
Interprets Health Net policies and procedures concerning claim issues, contracts and benefits
Coordinates with Provider Network Management when unable to resolve issues with providers and internal departments
Participates in process improvement activities and facilitates corrective actions
Prepares monthly reports to management documenting issues, action plans and resolutions
Researches and responds to Shared Risk Discrepancies from Participating Provider Groups
Performs other duties as assigned
Complies with all policies and standards

Requirements

What you’ll need

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future
Bachelor’s degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or work experience providing equivalent background required
Minimum of two years experience in medical claims review and/or claims appeal required
Experience with New York state provider fee schedules preferred
Experience with independent dispute resolution (IDR) related to the No Surprises Act preferred
Experience monitoring rate updates and changes preferred
Experience in claims analysis preferred
Candidates who reside in the Tri-state area (NY, NJ, CT, PA) are preferred

Benefits

Comp & perks

Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Additional forms of incentives may be included in total compensation
Equal opportunity employer committed to diversity