Director – Grievance & Appeals

🔥 20 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $107.7k - $199.3k / year

⏰ Full Time

🔴 Lead

👔 Director

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Oversee member appeals and grievance processes • Direct and ensure efficient operational management of appeals and grievance departments/functions • Participate on internal committees and provide input on risk assessment activities and regulatory changes • Design and implement processes, policies, trainings and procedures for regulatory compliance • Address below-standard performance and resolve risk management issues • Track and trend preventable issues and grievances and lead procedural improvement committees • Minimize legal and financial risk for providers, employers and members • Determine potential loss and financial risk of unusual occurrence cases • Identify need for in-house legal involvement and coordinate with plan attorneys on litigated cases • Help oversee case preparation and research • Appear in court for small claims and administrative law judge cases • Develop operational budgets and complete forecasts and variance reporting • Lead development of Business Area Requirement Reports and business cases • Provide guidance, policy interpretation and compliance support across the Health Plan • Perform other duties as required

🎯 Requirements

• Must reside within the state of Florida • Bachelor's Degree in a related field or equivalent experience • 5+ years of experience in grievances, appeals, or healthcare law related fields • Previous management experience in managed care operations • Experience managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff • Master's Degree preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • 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

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