Grievance & Appeals Coordinator II

🔥 8 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $23 - $39 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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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

• Analyze and resolve verbal and written claims and authorization grievances/appeals from providers and members • Resolve state inquiries related to complaints, grievances and appeals • Review and process member and provider grievances and appeals within applicable regulations, policies and procedures • Review claim grievances for reconsideration and approve/deny based on determination level or prepare for medical review presentation • Prepare cases for medical review as necessary • Review and determine whether claim grievances include potential quality or access issues • Collaborate with subject matter experts to obtain benefit and/or clinical opinions/interpretations of complex cases • Serve as liaison between members, providers, 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 • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• Bachelor’s degree in related field or equivalent experience • 2+ years of claims, contracting, or related experience in a managed care environment • Experience investigating and resolving expressions of dissatisfaction from members and providers • Strong written and oral communication skills • Ability to review and process member and provider grievances and appeals within federal, state and organizational regulations, policies and procedures • Ability to review claims grievances for reconsideration and approve/deny based on determination level or prepare for medical review • Ability to determine whether claim grievances include potential quality or access issues • Ability to collaborate with subject matter experts to obtain benefit and/or clinical opinions/interpretations of complex cases

🏖️ Benefits

• 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 • Competitive pay • Additional forms of incentives may be included in total compensation

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