Behavioral Health QI Lead & Appeals Coordinator (Remote)

Centene Corporation; United States; Hybrid; USD 46,000 - 84,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Job summary

Centene Corporation is seeking a Clinical Quality Improvement professional to analyze, develop, and monitor initiatives ensuring compliance with customer expectations in behavioral health.

The role involves reviewing clinical information for appeals to determine medical necessity, preparing cases, and driving PIPS while maintaining NCQA/state documentation standards. Experience in Behavioral Healthcare is preferred, with RN or related field credentials.

Qualifications

• Associate’s Degree in Nursing or related field required.
• 2+ years in Clinical Nursing or Behavioral Health required.
• 1+ years experience in Quality, Managed Care or Healthcare Administration required.
• Experience in Behavioral Healthcare field preferred.

Responsibilities

• Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations.
• Lead Behavioral Health Performance Improvement Projects (PIPS).
• Review clinical information for appeals to determine medical necessity.
• Prepare cases for appeals that do not meet medical necessity.
• Maintain files, logs, documentation including communication in accordance with NCQA and State standards.
• Investigate and resolve behavioral health quality of care complaints and grievances.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical Nursing

Behavioral Health

Quality Improvement

Education

Associate’s degree in Nursing or related field

Job description

Centene Corporation is seeking a Clinical Quality Improvement professional to analyze, develop, and monitor initiatives ensuring compliance with customer expectations in behavioral health.

The role involves reviewing clinical information for appeals to determine medical necessity, preparing cases, and driving PIPS while maintaining NCQA/state documentation standards. Experience in Behavioral Healthcare is preferred, with RN or related field credentials.