Grievance and Appeals Coordinator II

1 month ago


Tempe, United States Centene Corporation Full time

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.
 

Position Purpose:

Analyze and resolve verbal and written claims and authorization grievance/appeals from providers and members. Resolve all State inquires related to complaints, grievances and appeals.

• Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures
• Review claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation. Prepare cases for medical review as necessary
• Review and determine if claim grievance includes a potential quality or access issue
• Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases
• Serve as liaison between member, provider regulatory agencies and internal staff. Correspond with key individuals regarding grievance and appeal decisions.
• Act as subject matter expert regarding grievances and appeals.
• Lead Appeals and Grievance Committee

Education/Experience: Bachelor’s degree in related field or equivalent experience. 2+ years of claims, contracting, or related experience in a managed care environment.

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.



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