Remote Grievance & Appeals Specialist II

Centene; EE. UU.; A distancia; USD 32.000 - 55.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote/hybrid/work-from-home options

Descripción de la vacante

Centene is seeking a remote Grievance & Appeals Coordinator II to analyze and resolve member and provider complaints and appeals. The role supports reviewing grievances within regulations, preparing cases for medical review, and coordinating with internal teams and health plan partners.

Ideal candidates have a bachelor’s degree (or equivalent) and 2+ years in claims, contracting, or managed care. The position offers competitive pay and a comprehensive benefits package with

Formación

• Bachelor's degree in related field or equivalent experience.
• 2+ years of claims, contracting, or related experience in a managed care environment.

Responsabilidades

• Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures.
• Review claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation.
• Prepare cases for medical review as necessary.
• Review and determine if claim grievance includes a potential quality or access issue.
• Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.
• Serve as liaison between member, provider regulatory agencies and internal staff.
• Correspond with key individuals regarding grievance and appeal decisions.
• Act as subject matter expert regarding grievances and appeals.
• Lead Appeals and Grievance Committee
• Performs other duties as assigned
• Complies with all policies and standards

Conocimientos

Grievance & Appeals process

Claims investigation

Written & oral communication

Remote collaboration

Educación

Bachelor's degree or equivalent experience

Descripción del empleo

Centene is seeking a remote Grievance & Appeals Coordinator II to analyze and resolve member and provider complaints and appeals. The role supports reviewing grievances within regulations, preparing cases for medical review, and coordinating with internal teams and health plan partners.

Ideal candidates have a bachelor’s degree (or equivalent) and 2+ years in claims, contracting, or managed care. The position offers competitive pay and a comprehensive benefits package with