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.

Key Details: Centene Pharmacy Services is hiring a remote Grievance & Appeals Coordinator II. The ideal candidate will have experience investigating and resolving expressions of dissatisfaction (i.e., complaints and grievances) from members and providers as well as strong written and oral communication skills for collaborating with Pharmacy Services-internal teams and our Health Plan partners.

• 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
• 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 claims, contracting, or related experience in a managed care environment.

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
 

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