Director, Grievance & Appeals

Centene Corporation•Remote-FL, FL

2d•$107,700 - $199,300

About The Position

The Director, Grievance & Appeals oversees member appeals and grievance processes and directs their efficient operational management, with a focus on execution, outcomes, continual improvement, and performance enhancement. The role participates in internal committees addressing risk assessment and regulatory changes; develops processes, policies, training, and procedures to support regulatory compliance; and addresses below-standard performance and risk-management issues. The director tracks preventable issues and grievances and leads a committee focused on procedural improvements. The position minimizes legal and financial risk, assesses potential losses in unusual cases, identifies when in-house legal involvement is needed, and coordinates with plan attorneys on litigated cases. It also represents the Health Plan in small-claims and administrative law judge cases. The role provides fiscal management, including operational budgets, forecasts, and variance reporting; leads development of Business Area Requirement Reports and business cases; and serves as a Health Plan point of contact for policy guidance, interpretation, and compliance with internal and external requirements. The position is based in Florida, and the candidate must reside in the state.

Requirements

Must reside within the state of Florida.
Bachelor's degree in a related field or equivalent experience.
At least 5 years of experience in grievances, appeals, or healthcare law-related fields.
Previous management experience in managed care operations, including management of cross-functional teams on large-scale projects, or supervisory experience that includes hiring, training, assigning work, and managing staff performance.

Nice To Haves

Master's degree preferred.

Responsibilities

Oversee member appeals and grievance processes and ensure efficient operational management focused on execution, outcomes, continual improvement, and performance enhancement.
Participate in internal committees and provide input and guidance on risk assessment activities and the impact of regulatory changes.
Design and implement processes, policies, training, and procedures to ensure compliance with new and existing regulations.
Address below-standard performance and implement mechanisms to resolve risk-management issues.
Track and trend preventable issues and grievances, and lead a committee focused on organizational procedural improvements.
Minimize legal and financial risk while protecting the interests of providers, employers, and members; determine potential loss and financial risk in unusual cases.
Identify the need for in-house legal involvement on sensitive cases and coordinate with plan attorneys on litigated cases, including case preparation and research.
Appear in court for small-claims and administrative law judge cases to ensure appropriate Health Plan representation.
Develop operational budgets and complete forecasts and variance reporting.
Lead development of Business Area Requirement Reports (BARR) and business cases to ensure systematic capabilities and configuration.
Provide guidance, input, and interpretation of policies across the Health Plan and ensure compliance with internal and external requirements.
Perform other duties as required.