This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Facilitates the member grievance and appeal process by investigating, documenting and preparing case files to meet all regulatory requirements. - Investigate member grievance and appeal by gathering supporting documentation from internal departments, contracted Provider Organizations (PO), and non-contracted entities as indicated. - Communicate with the members or providers to request and gather pertinent information. Follow up as needed and document accordingly. - Track and monitor movement of assigned cases through SCAN’s functional units and systems, to ensure compliance with designated timelines. - Respond to requests for information from all regulatory agencies within required timeframes. - Respond to and close cases within designated regulatory time requirements as identified by case types. Generate and send appropriate communications. - Understand SCAN benefit structure and maintain current and additional information as it relates to Grievances and Appeals services. - Utilize department desktop procedures, workflows, job aids and training material. Identify barriers to work processes and bring to the attention of the supervisor/manager. - Maintain the member‘s right to privacy and protect SCAN operations by keeping information confidential. - Adhere to all quality, compliance and regulatory standards to achieve HCS and SCAN outcomes. - Contribute to team effort by accomplishing related results as needed. - Actively support the achievement of SCAN’s Vision and Goals. - Other duties as assigned. Qualifications - High School Diploma or equivalent experience - 2+ years in customer service and/or grievance and appeal in healthcare setting - Experience providing professional customer service. - Performs work under minimal supervision. - Handles complex issues and problems, and refers only the most complex issues to higher-level staff. - Possesses comprehensive knowledge of subject matter. - Provides leadership, coaching, and/or mentoring to a subordinate group. - May act as a lead or first-level supervisor Benefits - Base Pay Range: $20.14 - $30.00 per hour - Work Mode: Mostly Remote - An annual employee bonus program - Robust Wellness Program - Generous paid-time-off (PTO) - 11 paid holidays per year, plus 1 additional floating holiday - Excellent 401(k) Retirement Saving Plan with employer match - Robust employee recognition program - Tuition reimbursement - An opportunity to become part of a team that makes a difference to our members and our community every day! Company Description Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The hours of this role will fall between 8am-9pm EST Mon-Fri. Highly technical Customer Service expert with depth of knowledge within a health care setting. This position will require highly analytical, advanced ability to connect with the member, with a depth of knowledge in resolving and navigating within a health care setting. This position supports medical health plan clients with benefit needs and will also have the expanded responsibility of recommending vendor programs and services. Although this position is within a call center, it differs from typical call center roles due to the requirement and ability to independently seek solutions to customer needs. - Responsible for providing high level of service to inbound calls, outbound calls, direct messaging and digital chat customers with more complex medical conditions and/or needs. - Will educate customer on Medical health plan benefit package and vendors to enable optimal health outcomes. - Conducts in-network provider searches and facilitates appointment scheduling. - Provides advanced support with prior authorizations, helping to navigate next steps on denials and/or missing information. - Investigates and resolves escalations, issues, complaints obtaining necessary information from policies, procedures, or practices. - Highly organized with ability to follow-up timely and communicate proactively to customer and other necessary parties. - May serve as primary contact and liaison between customers, health plans, service centers, and/or functional areas. - Must have thorough technical knowledge of assigned products and excellent communication skills. - Understands when to seek support by coaches and leadership for issue resolution. - Requires the delivery of complex business resolution services in customer service via inbound calls, outbound calls and portal messaging to customers. - Responds to inquiries from policy holders where additional information or research is needed. - Must listen intently and have ability to interpret verbal cues from customers. - The position requires high level of compassion and empathy, excellent interpersonal skills, strong communication and comfortability in sharing intricate and/or difficult messages. - Knowledge and understanding of Customer Service and business/operating processes and procedures required. - Must be a champion of change and adapt well to frequent adjustments to procedures or guidance. Qualifications - High School diploma or GED required. - Required experience in US Commercial Medical Call Operations Background: - Proclaim - CCF / CDHP skillset - Medical OneGuide - OneView - Proven ability to listen, understand customers current & future needs, and interpret information from others. - Excellent communication skills in the spoken and written word. - Creative problem-solving and analytical skills. - Proven ability to independently manage day in a fast-paced environment. - Proficiency in Word and Outlook. Requirements - Strong KPI scores over the last 12 months; must be meeting or exceeding current targets. - ≥90% in Quality. - ≥90% in Contact Resolution. - Meeting Overall Agent Survey Result (target varied by team). - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. Company Description Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Military veterans and military spouses bring essential experience to our workforce, and we encourage them to apply! Member Advocates will be responsible for handling both inbound and outbound calls to support our healthcare client. In this role, advocates are expected to deliver exceptional customer service by adhering to established protocols and guidelines. Advocates will support members through a variety of needs such as: - Billing - Quoting - Understanding medical or pharmacy benefits - Providing requested materials - Researching claims - And so much more! They will utilize various web-based systems to efficiently address and resolve customer inquiries, ensuring a seamless and satisfactory experience for each caller. Our focus is creating a fantastic member experience. Advocates will need to be able to make the process easy for members, demonstrate that you care, and ultimately, resolve their concerns. Employees on this program do more than simply provide services to members. They advocate for them! - 7 weeks of paid, mandatory training: 100% attendance required. - All equipment provided. Work from home! - Call center hours: Monday-Friday, 8 AM-9 PM EST; Saturday, 9 AM-7:30 PM EST - Competitive benefits, PTO, growth, and development opportunities. Important: At the end of the application, you’ll see a screen titled “Digital Interview.” Please wait a moment for the purple link to load—this will take you to the required assessments. These must be completed from a computer or laptop. Assessments must be completed before moving forward in the process. Qualifications - High School Diploma or GED - Prior call center or customer service experience highly desired - Effective verbal and written communication skills - Ability to multi-task - Knowledge on how to operate a computer, use internet search engines, and navigate multiple windows/tabs - Ability to sit for extended periods of time - Ability to successfully pass a background investigation and drug screen - Must successfully pass preemployment criteria testing and internet speed test Requirements - Enclosed and secure work area with zero distractions - Must have the ability to provide a non-cellular high speed internet service such as Fiber, DSL, or cable modems for a home office. - Must be able to meet the minimum internet speed requirements of 20 mbps download and 12 mbps upload. - Hotspots, satellite and wireless internet service is NOT allowed for this role. Responsibilities - Answer customer inquiries with professional courtesy, providing exceptional customer service to each customer, based on client specific instruction. - Document each customer's inquiry information into a database. - Verify customer's information, making corrections and updates as needed. - Actively listen to recognize opportunities to offer additional information to callers ensuring the caller and client has received the best customer service experience possible. - Follow-up with callers as necessary. - Use statistical contact center data to make improvements to performance. - Shift and Schedule adherence. Company Description Senture is home to a global family with people from various backgrounds and lifestyles. We will always embrace diversity and never discriminate against employees or applicants based on gender identity or expression, sexual orientation, race, religion, age, national origin, citizenship, disability, pregnancy status, veteran status, or other differences.

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. 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 ***Highly preferred that candidate resides in the state of Florida in either Southern Florida, Orange County, Hillsborough County or surrounding areas. Role will require local travel.*** Position Purpose: Serves as a vital link between members and the healthcare system, focusing on improving health outcomes by identifying and closing care gaps. This role emphasizes community engagement, member education, and collaboration with providers and internal teams to ensure members receive timely, appropriate care and support. - Conduct outreach to members in the community to identify care gaps and connect them with appropriate healthcare services and resources. - Perform home visits or community-based assessments to evaluate member needs and identify social determinants of health that may prevent members from accessing preventive or follow-up care, and facilitate care coordination. - Serve as a member advocate by helping individuals navigate complex healthcare and social service systems. Assist with scheduling appointments, understanding care plans, and accessing benefits or entitlements, ensuring members receive the support needed to close care gaps and maintain continuity of care - Collaborate with providers to share quality performance data (e.g., HEDIS, CAHPS) and support improvement initiatives. - Educate members on preventive care, chronic condition management, and available community resources. - Document member interactions, care gap closures, and referrals in the appropriate systems. - Partner with internal departments (e.g., Quality, Care Management, Provider Relations) to align efforts and improve member outcomes. - Monitor and report on outreach effectiveness and care gap closure metrics. - Maintain compliance with state and federal regulations and organizational policies. - Participate in seasonal campaigns and quality initiatives to improve member engagement and health outcomes. - Serve as a community ambassador, building relationships with local organizations and stakeholders. - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Bachelor's Degree Social Work, Public Health, Nursing, or related field; or equivalent experience required 2+ years In community health or healthcare quality required Experience working with health plan members and navigating community resources required Familiarity with Medicaid / Medicare programs and quality measures (e.g., HEDIS) required Strong communication and interpersonal skills Licenses/Certifications: LCSW- License Clinical Social Worker preferred RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred Pay Range: $27.02 - $48.55 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