What are the responsibilities and job description for the Grievance & Appeals Specialist II position at Arizona Complete Health?
You could be the one who changes everything for our 26 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 Purpose: Responsible for reviewing, investigating and tracking member grievances and appeals, and provider claims disputes. Responsible for coordinating as necessary with the G&A Administrator and outside counsel during state fair hearing proceedings.
- Screen all incoming grievances, appeals and provider claim disputes to ensure they are in compliance with the Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures.
- Coordinate conferences with appropriate parties for appeal proceedings.
- Conduct grievance investigations through internal and external interviews, inspection of relevant documentation, and interpretation of appropriate legal authorities/policies.
- Write investigative reports and Notices of Decision or Resolution that meet ADHS/DBHS standards.
- Provide technical support with respect to Notices of Action.
- Audit files on an ongoing basis in preparation for quarterly, annual, and ad-hoc audits.
- Manage daily entries into the DBHS Office of Grievance and Appeals database.
- Coordinate with all relevant departments, as necessary, to streamline the G&A process.
- Assist the G&A Administrator and outside counsel in preparation for Fair Hearings.
- Administer all grievance system processes competently, expeditiously and equitably to ensure that appeals, SMI Grievances and claim disputes are effectively and efficiently adjudicated and/or resolved.
- Assist the G&A Administrator in providing education and training to company staff and external providers.
- Other assignments as may be requested.
Education/Experience: Bachelor’s degree or equivalent in a related field. 4 years of behavioral health or physical health experience. Experience processing grievances and appeals preferred. Licenses/Certifications: Certified by Council on Licensure, Enforcement and Regulation (CLEAR) or by an equivalent certification program approved by ADHS/DBHS. Certification must be obtained 6 months of hire.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
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.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible spending account
- Health insurance
- Paid time off
- Vision insurance
Schedule:
- Monday to Friday
Education:
- Bachelor's (Preferred)
Experience:
- Behavioral health: 4 years (Preferred)
- grievance and/or appeals: 1 year (Preferred)
Work Location: Remote
Salary : $42,800 - $54,200