Description
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.
THIS POSITION IS REMOTE/WORK FROM HOME SUPPORTING OUR ILLINOIS HEALTH PLAN MEDICAID AND YOUTHCARE GRIEVANCE & APPEALS PROCESSING TEAM.
THE WORK SCHEDULE IS MONDAY - FRIDAY 8AM - 5PM CENTRAL TIME ZONE WITH OVER-TIME AS NEEDED DURING THE WEEK AND APPROXIMATELY EVERYOTHER WEEKEND FOR SOME ON-CALL DUTIES.
AS A LEAD, RESPONSIBILITIES WILL INCLUDE:
- MAINTAIN A SMALLER CASELOAD
- PROVIDE UPDATES ON STATUS' OF: DAILY CASE COMPLETION BY ASSIGNED TEAM MEMBERS, ERROR MANAGEMENT, RUN DAILY HUDDLES, CONTRIBUTE TO JOB AIDS, Q&AS, SUPPORT PROCESS CHANGES, COACHING STAFF, AND SUPPORT STATE FAIR HEARING PROCESS AS NEEDED; AMONG OTHER DUTIES.
Position Purpose:
Provide support and direction for the daily operations of the appeals function
- Provide consultation for problem resolution for appeals staff and monitor team work output to ensure compliance with internal and NCQA standards
- Identify training, process improvement and resource needs to maximize team performance and recommend action plans to management
- Review denial and appeal letters as needed to ensure appropriate content and message
- Prepare for state/health plan audits, response to complaints and request for state fair hearing documentation
- Prepare monthly reports, logs, and other health plan or state contractual requirements
- Review and monitor team workload and output to ensure optimum efficiency and accuracy
- Serve as the point of contact for issues that arise from members, providers and internal team
- Train and educate new and existing team on processes, policies and procedures, and contract or market requirements
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience:
Bachelor’s degree in related field or equivalent experience. 2+ years of grievance and appeals experience in a Healthcare or Managed Care setting.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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
