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.THIS POSITION IS REMOTE/WORK FROM HOME WITH 10% TRAVEL FOR IN-PERSON GRIEVANCES OR MANDATORY MEETINGS. APPLICANTS MUST RESIDE IN THE STATE OF PENNSYLVANIA.THE SCHEDULE IS MONDAY - FRIDAY, 8AM - 5PM.Position Purpose: Analyze and resolve verbal and written claims and authorization grievance/appeals from providers and members. Resolve all State inquires related to complaints, grievances and appeals.
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
10% travel for mandatory meetings or in-person grievances
Education/Experience: Bachelor’s degree in related field or equivalent experience. 2+ years of claims, contracting, or related experience in a managed care environment.Pay Range: $22.36 - $38.07 per hourCentene 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. Total compensation may also include additional forms of incentives.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.