Grievance & Appeals Coordinator II

Centene Corp.; EE. UU.; A distancia; USD 32.000 - 55.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work schedules (remote / hyb/

Remote or office work arrangements

Descripción de la vacante

Centene Corp. is seeking a remote Grievance & Appeals Coordinator II to analyze and resolve member and provider grievances and appeals, and to manage inquiries under federal, state, and internal regulations.

The role emphasizes collaboration with Pharmacy Services teams and health plan partners, requires a bachelor’s degree and 2+ years of managed care experience, and offers comprehensive benefits and flexible remote/hybrid schedules.

Formación

• Bachelor’s degree in related field or equivalent experience.
• 2+ years of claims, contracting, or related experience in a managed care environment.
• Strong written and oral communication skills for collaboration.

Responsabilidades

• Review and process member and provider grievances and appeals within regulations and policies.
• Review claim grievance for reconsideration and determine approval/denial or prepare for medical review.
• Prepare cases for medical review as necessary.
• Review for potential quality or access issues in grievances.
• Collaborate with subject matter experts for opinions on complex cases.
• Serve as liaison between member, provider regulators 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.

Conocimientos

Grievance resolution

Claims analysis

Verbal communication

Written communication

Educación

Bachelor's degree in related field

Descripción del empleo

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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.

Key Details:

Centene Pharmacy Services is hiring a remote Grievance & Appeals Coordinator II. The ideal candidate will have experience investigating and resolving expressions of dissatisfaction (i.e., complaints and grievances) from members and providers as well as strong written and oral communication skills for collaborating with Pharmacy Services-internal teams and our Health Plan partners.

• 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

• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience:

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

Pay Range: $23.23 - $39.61 per hour

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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act