LTSS Compliance Specialist

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

The Long-Term Services and Supports (LTSS) Compliance Specialist ensures that LTSS members and providers receive timely eligibility resolution communications, and will develop and maintain a system to track LTSS member eligibility status via data and other evidence of eligibility, including MEDI, PCF and 834 file. Ensures all contractual communication requirements are completed for notifications to other MCO's, DRS or IDOA on a monthly basis for disenrolled HCBS membership.

This position is responsible for receiving and responding to the more difficult customer inquiries and complaints made to State department, Department of Insurance or any other outside agency or vendor. This includes requests for dis-enrollment for cause, external reviews and state fair hearings. This position investigates and researches complaints and participates in negotiating solutions. Conducts proactive customer services activities, and may conduct periodic surveys to assess the effectiveness of the program.

• Serve as subject matter expert with LTSS eligibility: provide general information, verify information; and refer individuals to applicable external agency, office or department for further assistance as needed
• Investigate complaints from customers and participate in negotiating solutions
• Conduct proactive customer service activities inside and outside the department
• Investigate all requests for external review and provides written summary to support the health plan’s decision
• Investigate all requests for dis-enrollment for cause and provide written response to the requesting state agency
• Troubleshoot eligibility issues and interfaces with IDOA/DRS/HFS
• Responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of external complaints
• Communicate with appropriate parties on relevant issues, implications and decisions
• Analyze and identify trends
• Communicate with LTSS providers on eligibility issue resolutions
• Work with Enrollment and Finance departments to resolve LTSS member discrepancies
• Support the Network Development team with provider claims issues
• Manage tracking for disenrolled HCBS membership and ensures appropriate documentation on HCBS members transitioning to the Plan is received timely.
• Report monthly metrics on LTSS disenrollments to leadership
• Report compliance of HCBS records transmission for disenrolled members
• May be involved in the release of information to vendors or external agencies following all HIPPA guidelines and expectations.
• May conduct periodic customer satisfaction surveys, prepare reports, and other departmental projects
• Perform other duties as assignedAdditional Responsibilities:
  
  

Candidate Education: Required A High School or GED. Preferred A Bachelor's Degree in a related field

Candidate Experience: Required 3 years of experience in managed care

Preferred Other Experience In Customer Service

Licenses and Certifications: A license in one of the following is required:

Pay Range: $54,000.00 - $97,100.00 per year

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.