Grievance & Appeals Coordinator Ii
Job Description
You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ** Applicants for this position have the flexibility to work remotely from their home anywhere within the Central or Eastern time zone **
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
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Job Detail
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Job IdJD4273842
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IndustryNot mentioned
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Total Positions1
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Job Type:Full Time
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Salary:Not mentioned
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Employment StatusPermanent
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Job LocationIndiana, United States
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EducationNot mentioned