Key Facts

Remote From:

Full time

Expert & Leadership (>10 years)

English

Hard Skills

Appeals Case Management Systems Medicare Information Privacy Compliance Management Product Knowledge Medicare Meeting Facilitation

Other Skills

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Distributed Team Management
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Record Keeping
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Communication
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Teamwork
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Organizational Skills
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Detail Oriented

Roles & Responsibilities

High School Diploma or equivalent required
1+ years of experience in Managed Care Organization, health insurance, physician's office, hospital, or Medicare Advantage operations (i.e. claims, call center, mailroom)
Experience in Medicare appeals or related field preferred
Familiarity with Medicare regulations and CMS guidelines; basic knowledge of dual-eligible (Medicare and Medicaid) benefits preferred

Requirements:

Receive, review, log, and perform initial data entry of appeal requests; triage to determine appropriate area for resolution; identify urgent cases for expeditious routing
Maintain accurate records and ensure compliance with CMS regulations; classify cases appropriately; ensure confidentiality and security of sensitive information
Generate member and provider written communications when required; coordinate with multiple teams to ensure timely resolution
Participate in meetings; assist with special projects; perform other duties as assigned; comply with all policies and standards

Centene Corporation

About Centene Corporation

Centene Corporation provides high-quality healthcare services to members in all 50 states. Since its founding in 1984, Centene has worked to transform the health of communities, one person at a time. Centene is the largest Medicaid managed care organization in the country and provides a portfolio of services to government sponsored healthcare programs. Centene believes that healthcare is best delivered locally. Our local health plans offer a range of health insurance solutions with a focus on providing accessible care to uninsured and under-insured individuals. Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans). Centene also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services. Centene’s hiring practices reflect the composition of the members and communities we serve, allowing us to deliver quality, culturally sensitive healthcare to millions of members. Centene employees help change the world of healthcare and transform our communities. To learn more about career opportunities with Centene, visit: https://jobs.centene.com/

Company type: XLarge

Founded: 2018

Company size: 10001

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Job description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Shifts will be Monday - Friday working 8am - 5pm CST.

Position Purpose:
Responsible for ensuring proper appeal classification, and identification of valid appeals, through intake and triage of member and provider appeal cases efficiently, and in compliance with regulatory requirements. This role requires strong attention to detail, organizational skills, and the ability to coordinate with multiple teams to ensure timely resolution of appeals.

Maintain comprehensive knowledge of all products.
Receive, review, and log appeal requests in the applicable appeal system. Responsible for initial data entry function of appeals activity into applicable appeals systems.
In accordance with both company policy and governmental regulations, triage appeal requests to determine appropriate area for resolution.
Appropriately identify urgent cases and process expeditiously to ensure timely routing to other areas.
Maintains accurate records, and ensures compliance with CMS (Centers for Medicare & Medicaid Services) regulations.
Generate member and provider written communications when required.
Ensure appropriate case classification is entered for all cases reviewed.
Ensure confidentiality and security of sensitive information.
Actively participate in meetings.
Assist with special projects and perform other duties as necessary.
Performs other duties as assigned.
Complies with all policies and standards.

Education/Experience:
High School Diploma or equivalent required. 1+ years Managed Care Organization, health insurance, physician's office, hospital, or Medicare Advantage operations (i.e. claims, call center, mailroom) required. Experience in Medicare appeals, or related field preferred. Experience in handling requests related to dual-eligible members preferred. Familiarity with Medicare regulations and CMS guidelines with basic knowledge and understanding of the process for enrollees that have both Medicare and Medicaid benefits preferred.

Pay Range: $19.43 - $32.98 per hour

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

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