Grievance %26 Appeals Coordinator II

Centene Corporation Maitland , FL 32751

Posted 7 months ago

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

Education/Experience: Bachelor's degree in related field or equivalent experience. 2 years of claims, contracting, or related experience in a managed care environment.

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.


icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Long Term Care Coordinator I

Centene Corporation

Posted 4 days ago

VIEW JOBS 10/11/2019 12:00:00 AM 2020-01-09T00:00 Position Purpose: Responsible for members gaining access to needed services through coordination and integration of medical and long term care services for the purpose of orientation, care plan development, assessment, and care coordination. Complete assessments with members, caregivers, or providers to obtain information regarding client status, support system, and need for services for care plan development Monitor delivery of services and follow-up with members, caregivers, or provider s through in person visits and telephonic contact Authorize and coordinate referral for services Ensure provider services are delivered without gaps and identify functional deficiencies in plans of care Assist in coordinating the development of informal or voluntary services to integrate into the member care plan Collaborate with discharge planners, physicians, and other parties to ensure appropriate discharge plan, care plan, and coordination of acute care and long term care services Assist member with filing and resolving complaints and appeals Education/Experience: Bachelor's degree or Registered Nurse License and 2 years of care management experience, Licensed Practical Nurse and 4 years of care management experience, or 6 years of care management experience. Home health, discharge planning, or long term care experience preferred. Licenses/Certifications: Valid driver's license. LPN or RN preferred. Pennsylvania requirements: Bachelor's degree or Registered Nurse License and 3 years of experience in a social service or health care related setting, Licensed Practical Nurse and 5 years of experience in a social service or health care related setting, or 7 years of experience in a social service or health care related setting. Licenses/Certifications: Valid driver's license. LPN, LCSW or RN preferred. Iowa requirements: Bachelor's degree and 2 years of case management experience, or RN with 6 years of case management experience For North Carolina only: * Must reside in North Carolina * Must be licensed practitioners * Must be supervised by an RN, LCSW, or psychologist with trauma-based experience and training. Behavioral Health (BH) Managers and Full-Time BH Staff: These individuals shall be responsible for integrating into the clinical and care management teams to ensure Member's behavioral health needs are fully integrated into the service delivery system. * Must reside in North Carolina * Experience working in behavioral health managed care and clinical setting * Licensed behavioral health professional practicing within their scope 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. Centene Corporation Maitland FL

Grievance %26 Appeals Coordinator II

Centene Corporation