Clinical Review Clinician - Appeals

Centene Corporation; Canada; Remote; CAD 30,000 - 60,000; Full time

Job summary

Join a forward-thinking organization where you can make a significant impact on the health of millions. As a clinical professional in the Medical Management/Health Services team, you will perform essential clinical reviews to determine medical necessity for services. This role involves collaborating with various departments to enhance clinical appeals processes and ensure compliance with established standards. You will enjoy a flexible work environment, competitive pay, and a comprehensive benefits package designed to support your professional growth and work-life balance. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Benefits

Health Insurance

401K

Stock Purchase Plans

Tuition Reimbursement

Paid Time Off

Flexible Work Schedules

Qualifications

• Must have a California State RN license.
• 2-4 years of related experience required.

Responsibilities

• Perform clinical reviews to resolve and process appeals.
• Communicate with members, providers, and facilities regarding appeals.

Skills

Clinical Reviews

Communication Skills

Analytical Skills

Knowledge of NCQA

Utilization Management

Education

Graduate from an Accredited School of Nursing

Bachelor’s degree in Nursing

Job description

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.

Hours: 8am-5pm PST, Monday-Friday.

Must have a California State RN license.

Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicates with members, providers, facilities, and other departments regarding appeals requests.
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification: For Health Net of California: RN license required.

Pay Range: $26.50 - $47.59 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. Total compensation may also include additional forms of incentives.

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.