Appeals Specialist II

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 be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Position Purpose: Supports the documentation and processing of appeals, disputes and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely.

Prior experience working in claims, appeals and/or authorizations strongly preferred. Familiarity of TruCare Classic/Cloud, CenPas, Amisys, or Prime preferred.

• Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures

• Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files

• Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up

• Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision

• Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations

• Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations

• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience: Requires a High School diploma or GED. Requires 1 – 2 years of related experience. Knowledge of appeals, disputes and reconsiderations process preferred.

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