Manager, Grievance & Appeals

Centene Corporation; Pennsylvania; Hybrid; USD 70,000 - 126,000; Full time

Job summary

Centene Corporation is seeking a clinical professional to join the Medical Management/Health Services team, focused on managing member grievance appeals and state-level interactions. This role emphasizes due process, timely processing, and collaboration with government entities.

The ideal candidate has a Bachelor’s degree and 3+ years in healthcare law, grievances, and appeals, with leadership experience managing cross-functional teams.

Qualifications

• Bachelor’s degree in related field or equivalent experience.
• 3+ years of healthcare/law, grievances and appeals experience.
• Experience leading cross-functional teams on large-scale projects or supervisory experience including hiring and training.

Responsibilities

• Ensure that all appeals and grievances are processed within referred time frames and other contractual requirements.
• Monitor appeals and grievances and provide monthly reporting on trends to senior management.
• Ensure that all member and provider grievances are processed and investigated according to contract requirements.
• Work with state, local and federal governments, local community and the public related to grievance and appeals.
• Integrate federal and state law changes into the regulatory system related to grievance and appeals.
• Recommend solutions and coordinate corrective measures across departments to prevent recurrences.
• May provide training to agencies in developing procedures to comply with grievance and appeals requirements.
• Review and process incoming incident/accident reports.

Skills

Leadership

Team supervision

Hiring

Training

Project management

Education

Bachelor's degree or equivalent

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Ensure appropriate processing of member grievance appeals, provider appeals, or request for a State Fair Hearing. Perform duties as the point of contact with the State. Manage the day to day responsibilities of the Grievance & Appeals Coordinators.

• Ensure that the Grievance and Appeals department processes all appeals and grievances in accordance with referred time frames and other contractual legal requirements
• Monitor appeals and grievances and provide senior management with monthly reporting on trends
• Ensure that all members and provider grievances are processed and investigated according to contract requirements
• Work with various external constituencies, i.e., state, local and federal governments, local community and the public related to grievance and appeals
• Integrate federal and state law changes into company’s regulatory system related to grievance and appeals
• Recommend solutions and works with department and company staff to ensure problems are corrected and departments are advised of corrective measures to prevent recurrences
• May provide training and direction to agencies in developing procedures to comply with grievance and appeals requirements
• Review and process incoming incident/accident reports

Education/Experience:

Bachelor’s degree in related field or equivalent experience. 3+ plus years of experience in healthcare/law, grievances and appeals. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Pay Range: $70,100.00 - $126,200.00 per year

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