Position Purpose: Review, investigate and track all Medicare grievances, appeals, and provider claims disputes submitted, and pursue formal resolution for members and providers within required guidelines
Screen all incoming grievances, appeals and provider claim dispute to ensure they are in compliance with CMS guidelines and the corporation's policies
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
Prepare response letters for member and provider complaints, grievances and appeals
Conduct grievance and appeal investigations and provider claim dispute investigations through internal and external interviews, chart and contract audits, inspection, and interpretations of appropriate CMS guidance and policies
Maintain files on individual appeals and grievance cases
Manage the corporation's grievance and appeals database
Coordinate with all relevant departments to streamline the appeals and grievance processes
Help prepare cases for Medicare Appeals Committee (MAC) review
Identify training, process improvement and other ways to maximize team performance and recommend action plans to management
Education/Experience: Associate's degree in health care administration, social work, related field or equivalent experience. 1 years of social work community relations or grievance and appeals experience, preferably 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.