Grievance & Appeals Coordinator II
About The Position
Centene Pharmacy Services is hiring a remote Grievance & Appeals Coordinator II. The role analyzes and resolves verbal and written claims and authorization grievances and appeals from providers and members, and resolves State inquiries related to complaints, grievances, and appeals. The coordinator reviews and processes cases in accordance with applicable federal and state regulations and organizational policies and procedures. The position collaborates with internal Pharmacy Services teams, Health Plan partners, and subject matter experts, and serves as a liaison among members, providers, regulatory agencies, and internal staff. The coordinator also acts as a subject matter expert and leads the Appeals and Grievance Committee.
Requirements
- Bachelor’s degree in a related field or equivalent experience.
- At least 2 years of claims, contracting, or related experience in a managed care environment.
Nice To Haves
- Experience investigating and resolving expressions of dissatisfaction, including complaints and grievances, from members and providers.
- Strong written and oral communication skills for collaborating with Pharmacy Services internal teams and Health Plan partners.
Responsibilities
- Review and process member and provider grievances and appeals within federal, state, and organizational regulations, policies, and procedures.
- Review claim grievances for reconsideration and approve or deny them based on the determination level, or prepare them for medical review presentation.
- Prepare cases for medical review as necessary.
- Review and determine whether claim grievances include a potential quality or access issue.
- Collaborate with organizational subject matter experts to obtain benefit and/or clinical opinions or interpretations of complex cases.
- Serve as a liaison among members, providers, regulatory agencies, and internal staff.
- Correspond with key individuals regarding grievance and appeal decisions.
- Act as a subject matter expert regarding grievances and appeals.
- Lead the Appeals and Grievance Committee.
- Perform other duties as assigned.
- Comply with all policies and standards.
Benefits
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Holidays
- Flexible approach to work, with remote, hybrid, field, or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
