Grievance & Appeals Coordinator II
Posted on: 19 Jan 2021
Houston, TX
Job Description
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
Education/Experience:
Bachelors degree in related field or equivalent experience. 2+ years of claims, contracting, or related experience in a managed care environment.
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.
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
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IndustryHealthcare
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No. of Employees12, 000
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Website
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Jobs Posted917
