Manager, Grievance & Appeals

Trillium Community Health Plan; United States; Remote; USD 70,000 - 126,000; Full time

Job summary

Centene is seeking a Grievance & Appeals Coordinator to ensure timely processing of member grievances and provider appeals, serving as the primary point of contact with state authorities. The role manages day-to-day responsibilities of the Grievance & Appeals Coordinators, with a remote work arrangement aligning to PST and a strong preference for an Oregon RN license holder.

The candidate will supervise staff, monitor trends, and coordinate with state and federal bodies to implement regulatory

Qualifications

• 3+ years of experience in healthcare, law, grievances and appeals.
• Previous experience as a lead supervising staff and cross-functional teams.
• Bachelor’s degree in a related field or equivalent experience.

Responsibilities

• Process member grievances and provider appeals in accordance with contract requirements and timelines.
• Monitor and report monthly trends to senior management.
• Coordinate with state, local and federal entities related to grievance and appeals.
• Incorporate federal/state regulatory changes into the company’s grievance and appeals process.
• Provide training and guidance to agencies on procedures for compliance.
• Review and process incoming incident/accident reports.

Skills

Grievances & Appeals

Leadership

Healthcare law

Cross-functional teamwork

Education

Bachelor’s degree or equivalent

Job description

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.

Key Details

This is a remote position and the schedule will align with Pacific Standard Time (PST). Strongly prefer a candidate residing in Oregon who holds an active RN licensure in the state of Oregon.

• 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

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.

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