Grievance & Appeals Specialist I

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $23 - $39 / hour

⏰ Full Time

🟢 Junior

👻 Ghost score 0%

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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

• Review, investigate, and track member grievances and appeals and provider claims disputes • Coordinate with the G&A Administrator and outside counsel during state fair hearing proceedings • Validate, assign, and complete document folders and records for member grievances and complaints • Screen incoming grievances, appeals, and provider claim disputes for compliance with ARS and ADHS/DBHS policies and procedures • Coordinate conferences with appropriate parties for appeal proceedings • Conduct grievance investigations through internal and external interviews and relevant documentation inspection • Write investigative reports and Notices of Decision or Resolution • Provide technical support for Notices of Action • Audit files for quarterly, annual, and ad-hoc audits • Manage daily entries into the DBHS Office of Grievance and Appeals database • Coordinate with relevant departments to streamline the grievance and appeals process • Assist with Fair Hearings and provide education and training to company staff and external providers • Perform other assigned duties and comply with all policies and standards

🎯 Requirements

• Bachelor’s degree or equivalent in a related field • 2+ years of behavioral health or physical health experience • 1-2 years of related experience required • Experience processing grievances and appeals preferred • Certification by Council on Licensure, Enforcement and Regulation (CLEAR) or an equivalent certification program approved by ADHS/DBHS; certification must be obtained within 6 months of hire • Knowledge of Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures • Ability to conduct investigations through interviews, documentation inspection, and interpretation of legal authorities and policies • Ability to write investigative reports and Notices of Decision or Resolution meeting ADHS/DBHS standards

🏖️ Benefits

• competitive pay • 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