Manager, Grievance & Appeals

Visa Hunt; United States; Hybrid; USD 70,000 - 126,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work options

Job summary

Centene is seeking a clinical professional to join the Medical Management/Health Services team to lead and manage grievance and appeals processes for our large member base. This role focuses on ensuring timely, compliant handling of member and provider grievances and state hearing requests.

You will guide Grievance & Appeals Coordinators, monitor performance, and liaise with state regulators to implement changes in line with evolving laws and contract requirements.

Qualifications

• Bachelor's degree or equivalent experience in healthcare/law.
• 3+ years experience in healthcare, grievances and appeals.
• Previous lead or supervisory experience across cross-functional teams.

Responsibilities

• Ensure all grievances and appeals are processed within contractual and legal timeframes.
• Monitor appeals and grievances and provide monthly reporting on trends to senior management.
• Ensure member and provider grievances are processed and investigated per contract requirements.
• Collaborate with state, local and federal agencies, and other stakeholders related to grievance and appeals.
• Incorporate federal and state law changes into the company’s regulatory system for grievance and appeals.
• Recommend corrective actions and communicate results to prevent recurrences.
• Provide training and guidance to agencies on grievance and appeals procedures.
• Review and process incoming incident/accident reports.

Skills

Bachelor’s degree

3+ years experience

Leadership experience

Education

Bachelor’s degree in related field

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

Benefits:

Centene offers a comprehensive benefits package including:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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