Grievance & Appeals Specialist I

Centene Management Company LLC; Pennsylvania; Hybrid; USD 32,000 - 55,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work arrangements

Job summary

Centene Management Company LLC in Pennsylvania seeks a Grievance and Appeals Reviewer to investigate member grievances, appeals, and provider disputes, coordinating with legal and external counsel as needed. You will document findings, draft decisions, and support audits and reporting.

The role requires attention to regulatory standards, strong interviewing skills, and the ability to manage case files across multiple systems.

Qualifications

• Bachelor's degree or equivalent in a related field.
• 2+ years of behavioral health or physical health experience.
• Experience processing grievances and appeals preferred.

Responsibilities

• Review and investigate member grievances, appeals and provider claim disputes.
• Coordinate with G&A Administrator and outside counsel for state fair hearing proceedings.
• Write investigative reports and Notices of Decision/Resolution; ensure ADHS/DBHS standards.
• Audit files and maintain DBHS grievances database for audits.
• Assist in staff education and training on G&A processes.

Skills

Grievance investigations

Interviews

Documentation

Legal interpretation

Education

Bachelor's degree or equivalent

2+ years health experience

Job description

Position Purpose:

Responsible for reviewing, investigating and tracking member grievances and appeals, and provider claims disputes. Responsible for coordinating as necessary with the G&A Administrator and outside counsel during state fair hearing proceedings. Responsible for validating, assigning, and completing document folders and records for member grievances and complaints. Key Detail: Must reside in the state of Pennsylvania. Screen all incoming grievances, appeals and provider claim disputes to ensure they are in compliance with the Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures. Coordinate conferences with appropriate parties for appeal proceedings. Conduct grievance investigations through internal and external interviews, inspection of relevant documentation, and interpretation of appropriate legal authorities/policies. Write investigative reports and Notices of Decision or Resolution that meet ADHS/DBHS standards. Provide technical support with respect to Notices of Action. Audit files on an ongoing basis in preparation for quarterly, annual, and ad-hoc audits. Manage daily entries into the DBHS Office of Grievance and Appeals database. Coordinate with all relevant departments, as necessary, to streamline the G&A process. Assist the G&A Administrator and outside counsel in preparation for Fair Hearings. Administer all grievance system processes competently, expeditiously and equitably to ensure that appeals, SMI Grievances and claim disputes are effectively and efficiently adjudicated and/or resolved. Assist the G&A Administrator in providing education and training to company staff and external providers. Other assignments as may be requested. Performs other duties as assigned. Complies with all policies and standards.

Education/Experience:

Bachelor's degree or equivalent in a related field. 2+ years of behavioral health or physical health experience. Experience processing grievances and appeals preferred.

Licenses/Certifications:

Certified by Council on Licensure, Enforcement and Regulation (CLEAR) or by an equivalent certification program approved by ADHS/DBHS. Certification must be obtained 6 months of hire. 1-2 Years of related experience required. No Licenses required.

Pay Range:

$23.23 - $39.61 per hour.

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. 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.

• 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.

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.