Grievance & Appeals Specialist I

Centene Corporation

. Review, investigate, and track member grievances and appeals and provider claims disputes .

Posted 10/27/2026full-timeRemote • Pennsylvania • United StatesJunior💰 $23 - $40 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing grievances and appeals processes, including conducting investigations and writing comprehensive reports. Proficient in Arizona Revised Statutes and Department of Health Services policies, with a strong focus on compliance and documentation management.

Highest-signal resume keywords

Grievance And Appeals ManagementInvestigative ReportingKnowledge Of Arizona Revised StatutesBehavioral Health ExperienceCertification By Council On Licensure, Enforcement And Regulation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Grievance ProcessingAppeals CoordinationDocument InspectionReport WritingData Management

Soft Skills

CommunicationCollaborationProblem-Solving

Tools & Technologies

DBHS Office Of Grievance And Appeals Database

Certifications & Qualifications

CLEAR Certification

Industry Keywords

Arizona Department Of Health ServicesDepartment Of Behavioral Health ServicesComplianceFair HearingsBehavioral Health

About the role

Key responsibilities & impact

Review, investigate, and track member grievances and appeals and provider claims disputes
Coordinate with the G&A Administrator and outside counsel during state fair hearing proceedings
Validate, assign, and complete document folders and records for member grievances and complaints
Screen incoming grievances, appeals, and provider claim disputes for compliance with ARS and ADHS/DBHS policies and procedures
Coordinate conferences with appropriate parties for appeal proceedings
Conduct grievance investigations through internal and external interviews and relevant documentation inspection
Write investigative reports and Notices of Decision or Resolution
Provide technical support for Notices of Action
Audit files for quarterly, annual, and ad-hoc audits
Manage daily entries into the DBHS Office of Grievance and Appeals database
Coordinate with relevant departments to streamline the grievance and appeals process
Assist with Fair Hearings and provide education and training to company staff and external providers
Perform other assigned duties and comply with all policies and standards

Requirements

What you’ll need

Bachelor’s degree or equivalent in a related field
2+ years of behavioral health or physical health experience
1-2 years of related experience required
Experience processing grievances and appeals preferred
Certification by Council on Licensure, Enforcement and Regulation (CLEAR) or an equivalent certification program approved by ADHS/DBHS; certification must be obtained within 6 months of hire
Knowledge of Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures
Ability to conduct investigations through interviews, documentation inspection, and interpretation of legal authorities and policies
Ability to write investigative reports and Notices of Decision or Resolution meeting ADHS/DBHS standards

Benefits

Comp & perks

competitive pay
health insurance
401K
stock purchase plans
tuition reimbursement
paid time off plus holidays
flexible approach to work with remote, hybrid, field or office work schedules
additional forms of incentives may be included in total compensation