Complaints and Issues Specialist III

Business Area: Customer Care

Job Type: Full time

Position Purpose: Processes and documents customer complaints and issues (I.e., grievances, appeals, Claims Tracking Module) including moderate to high complexity cases based on regulatory requirements. Supports and collaborates with team members and other functions to document and identify a compliant solution for complaints and issues. Works directly with CMS to resolve complaints.

Key Details: 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.

Applicants for this job have the flexibility to work remote from home in the United States with preference given to Eastern time zone due to work schedule of 8:30am to 5pm.

Claims knowledge and experience working with Excel preferred as well as experience working with Facets.

• Preparing and submitting responses to independent dispute resolution (IDR) entities within five (5) business days of receipt

• Demonstrates excellent written communication skills, organization, and strong attention to detail, while maintaining accuracy under tight deadlines

• Processes, tracks, and maintains all received customer inquiries, complaints, and issues using internal tools as defined by the state and federal regulatory requirements and internal grievance and appeal policies and procedures

• Documents written issues and responses related to moderately complex customer complaints and issues to ensure regulatory compliance

• Investigates customer complaints and issues to determine root cause and identify appropriate resolution

• Influences effective communication with member/providers and stakeholders regarding the status of customer complaints and issues as per the defined guidelines

• Collaborates with internal stakeholders to ensure timely and effective resolution of customer complaints and issues to ensure adherence to quality standards, regulations, and confidentiality

• Works on development and implementation of policies and procedures for handling customer complaints and issues

• Ensures compliance with all relevant laws and regulations related to customer complaints and issues resolution

• Supports maintenance of monthly summary of open cases with aging and closely monitors timeframes to comply with all state and federal regulatory requirements

• Develops training materials and helps conduct training sessions for employees on customer complaints and issues

• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience: Requires a High School diploma or GED. Requires 2 - 4 years of related experience. May require vocational or technical education in addition to prior work experience. Vocation or technical education may include additional on-the-job training or continuous learning education. Experience in a contact center environment preferred.

Pay Range: $42,400 - $72,200 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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