Director, Grievance & Appeals

Job 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.

Must live near Raleigh, NC. Hybrid role with 2x per week in our Raleigh office.

Position Purpose : Responsible for oversight of member appeals and grievance processes. Directs and ensures the efficient operational management of appeals and grievance departments / function with emphasis on execution, outcomes, continual improvement and performance enhancement.

• Directs and ensures the efficient operational management of appeals and grievance departments / function with emphasis on execution, outcomes, continual improvement and performance enhancement.
• Participates on several internal committees to engage and offer input and guidance relative to risk assessment activities, impact of regulatory changes.
• Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations.
• Addresses areas of below-standard performance and implements mechanisms to resolve risk management issues.
• Tracks and trends preventable issues and grievances and leads a committee focused on organization procedural improvements.
• Minimizes legal and financial risk by taking appropriate measures to protect the interest of providers, employers and members.

Determines the potential loss and financial risk of unusual occurrence cases.

• Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research.
• Appears in court for small claims and administrative law judge cases to ensure appropriate representation of the Health Plan.
• Provides fiscal management and support including developing operational budgets and completing forecasts and variance reporting.
• Leads development of Business Area Requirement Reports (BARR) and business cases to ensure systematic capabilities and configuration.
• Acts as the point of contact for all areas of the Health Plan providing guidance, input and interpretation of policies, and ensuring compliance with internal and external requirements.
• Performs other duties as required.

Education / Experience : Bachelor's Degree in a related field or equivalent experience. Master's Degree preferred. 5+ years of experience in grievances, appeals, or healthcare law related fields.

Previous management experience in managed care operations, including managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

North Carolina Requirements : Current state RN license.Pay Range : $103,500.00 - $191,600.00 per year

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