• Job Description

  Req#: 1522056

  You could be the one who changes everything for our 28 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.
  

  Position is fully remote and will be supporting dental grievance and appeals cases.

  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

  • Validates member and medical provider demographic information including correct selection of a medical provider by specialty for healthcare service.
  • Determines whether members are eligible to receive health care benefits under the insurance program by determining the patients’ status/eligibility the Primary Care Manager (doctor) type, and the appropriate referral/authorization path.
  • Contacts medical provider offices by telephone, and makes confirmation calls to members for all urgent requests. Uses sound judgment in making decisions in order to keep the referral/authorization process moving forward in accordance with contractual timeliness standards.
  • Generates letters and reviews to validate that they are going to the correct providers/patients, and that the provider/patient demographics and reason(s) for services to be rendered are correct.
  • Responsible for accurately reporting individual production that includes outcome data such as closed transactions, duplicative transactions and requests.
  • Achieves successful solutions by reviewing situations and ensuring a full understanding before taking steps to resolve. Key components of this responsibility are objectively identifying problems, recognizing patterns, and determining solutions.
  • Responsible for outstanding customer service by producing results and achieving goals by tracking performance, improving work processes, and prioritizing work and tasks as an individual and team.
  • Maintain files on individual appeals and grievances by gathering, analyzing and reporting verbal and written member and provider complaints, grievances and appeals. Prepare response letters for member and provider complaints, grievances and appeals.
  • 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.
  • Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research.
  • May coordinate the Grievance and Appeals Committee.
  • Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information.
  • Review and determine if claim grievance includes a potential quality or access issue.

  Education/Experience: High school diploma or equivalent. Associate’s degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, critical thinking, and problem solving skills.

  Pay Range: $18.66 - $31.73 per hour

  Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.

  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.

  
  Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

• About the company

  Centene Corporation is a publicly traded managed care company based in St.

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