Manager, Grievance & Appeals

PA Health & Wellness; Pennsylvania; Hybrid; USD 70,000 - 126,000; Full time

Benefits offered by this job

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work schedules

Job summary

Centene is seeking a clinical professional to join our Medical Management/Health Services team to ensure proper processing of member grievances, provider appeals, and state fair hearings. You will serve as the primary contact with the State and oversee the daily activities of the Grievance & Appeals Coordinators.

Bachelor’s degree or equivalent experience is required with 3+ years in healthcare or law, plus leadership experience managing cross-functional teams on large projects.

Qualifications

• Bachelor’s degree in related field or equivalent experience.
• 3+ years in healthcare, law, grievances and appeals.
• Lead in a functional area with cross-functional teams on large projects or supervisory experience.

Responsibilities

• Ensure the Grievance and Appeals department processes all appeals and grievances on time and per contract requirements.
• Monitor appeals and grievances and provide monthly management reports on trends.
• Ensure proper processing and investigation of all member and provider grievances.
• Collaborate with state, local and federal agencies and the public on grievance and appeals issues.
• Incorporate federal and state law changes into the regulatory system for grievance and appeals.
• Recommend corrective actions and communicate measures to prevent recurrences.
• Provide training/direction to agencies on grievance and appeals procedures.
• Review and process incoming incident/accident reports.

Skills

Grievances & appeals

Leadership

Cross-functional team leadership

Regulatory compliance

Education

Bachelor’s degree in related field

Equivalent experience

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