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.