Grievance %26 Appeals Coordinator (Medicare)

Centene Corporation Woodland Hills , CA 91367

Posted 3 months ago

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.


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Grievance %26 Appeals Coordinator (Medicare)

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