Appeals Specialist II - Clinical Operations and Patient Advocacy in Healthcare Industry

Join the Centene Team as an Appeals Specialist II: Championing Patient Advocacy and Clinical Excellence Centene Corporation, a leading diversified national healthcare organization, is seeking a highly skilled and compassionate Appeals Specialist II to join our Medical Management/Health Services team. As a vital member of our clinical operations, you will play a pivotal role in ensuring that our 28 million members receive exceptional care and support. This is a unique opportunity to make a positive impact on patients' lives while advancing your career in the healthcare industry. About Centene and Our Culture Centene is a Fortune 500 company dedicated to providing high-quality, affordable healthcare services to underserved communities. Our mission is to improve the health and well-being of our members and the communities we serve. We value diversity, equity, and inclusion, and strive to create a workplace culture that is inclusive, supportive, and empowering. As an Appeals Specialist II, you will be part of a dynamic team that shares a passion for delivering exceptional patient care and advocating for those in need. Position Purpose and Key Responsibilities As an Appeals Specialist II, you will be responsible for supporting the documentation and processing of appeals, disputes, and reconsiderations to ensure compliance with state and National Committee for Quality Assurance (NCQA) requirements. Your expertise will help us navigate complex clinical issues and ensure that our members receive the care they deserve. Key responsibilities include: Performing data entry to support the tracking, logging, and processing of appeals, disputes, and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures. Preparing correspondence for appeals, disputes, and reconsiderations and maintaining documentation files. Reviewing and investigating appeals, disputes, and reconsiderations requests to determine applicable follow-up actions. Conducting research needed to evaluate, process, and respond to appeals, disputes, and reconsiderations to ensure timely decisions. Preparing case files, including supporting documentation and determinations needed to review, process, and report on appeals, disputes, and reconsiderations. Gathering appeals, disputes, and reconsiderations data to track and report on trends and final outcomes, including conducting outreach for updates on statuses, determinations, and explanations. Performing other duties as assigned and complying with all policies and standards. Requirements and Qualifications To be successful in this role, you will need: A High School diploma or GED. 1-2 years of related experience in healthcare, preferably in appeals, disputes, and reconsiderations. Knowledge of appeals, disputes, and reconsiderations processes, as well as regulatory and accreditation guidelines. Excellent analytical, communication, and interpersonal skills. The ability to work independently and as part of a team in a fast-paced environment. Preferred qualifications include: Experience working in a healthcare setting, particularly in medical management or health services. Familiarity with NCQA requirements and other regulatory guidelines. Strong research and analytical skills, with the ability to interpret complex data. Career Growth Opportunities and Learning Benefits At Centene, we are committed to the growth and development of our employees. As an Appeals Specialist II, you will have access to: Comprehensive training and onboarding programs to ensure your success in the role. Ongoing education and professional development opportunities to enhance your skills and knowledge. Career advancement opportunities within the company, including promotions and lateral moves. A collaborative and supportive work environment that encourages feedback and innovation. Work Environment and Company Culture Centene offers a flexible and supportive work environment, with a range of work arrangements to suit your needs: Remote work options, allowing you to work from the comfort of your own home. Hybrid work schedules, combining remote and office-based work. Field-based work opportunities, allowing you to engage with members and providers in the community. Office-based work environments, providing opportunities for face-to-face collaboration and teamwork. Compensation, Perks, and Benefits Centene offers a comprehensive benefits package, including: A competitive salary range of $19.62 - $33.36 per hour, depending on experience and qualifications. Health insurance, including medical, dental, and vision coverage. 401(k) and stock purchase plans to help you save for the future. Paid time off, including holidays and vacation days. A flexible approach to work, with remote, hybrid, field, or office-based work arrangements. Why Join Centene? By joining Centene as an Appeals Specialist II, you will be part of a team that is dedicated to making a positive impact on the lives of our members. You will have the opportunity to: Champion patient advocacy and clinical excellence in the healthcare industry. Work with a diverse and talented team of professionals who share a passion for delivering exceptional care. Develop your skills and knowledge through comprehensive training and education programs. Enjoy a flexible and supportive work environment that prioritizes work-life balance. Be part of a company that values diversity, equity, and inclusion, and is committed to making a positive impact on the communities we serve. How to Apply If you are a motivated and compassionate professional who is passionate about delivering exceptional patient care, we encourage you to apply for this exciting opportunity. Please submit your application today, including your resume and a cover letter, to: We look forward to hearing from you and exploring how you can join our team as an Appeals Specialist II. Apply for this job