Clinical Revew Clinician - Appeals

Centene Corp.; Georgia; Remote; USD 80,000 - 100,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote work options

Job summary

Centene Corp. seeks a remote Clinical Review Clinician – Appeals Nurses to perform clinical reviews and determine medical necessity for services under NCQA guidelines. The role focuses on appeal research, data review, and timely communication with members and providers.

Ideal candidates will have nursing licensure with 2–4 years’ related experience, familiarity with InterQual, and multi-state licensing or compact licensure. Centene offers flexible remote work options and extensive benefits.

Qualifications

• Requires nursing degree and licensure in willing states or compact licensure.

Responsibilities

• Prepare case reviews for Medical Directors by researching the appeal and applicable criteria.
• Ensure timely review, processing, and response to appeal per NCQA standards.
• Communicate with members, providers, and facilities regarding appeals.
• Generate appeals resolution communications for members and providers.
• Collaborate with leadership to improve consistency and efficiency of responses.
• Work with interdepartmental teams to improve processes to prevent recurrences per best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Skills

Appeals experience

Utilization management

InterQual

Communication

Education

Nursing degree (Licensed Practical Nurse, Registered Nurse)

Master’s in Behavioral Health or Social Work

Tools

InterQual

Job description

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.

Key Details:

Centene is hiring two remote Clinical Review Clinician – Appeals Nurses for our Ambetter & MI Medicaid Market. The ideal candidate will have appeals or utilization management experience and proficiency in using company policies and clinical decision based tools such as InterQual to evaluate medical necessity. This position will include researching and reviewing Provider Post-Service Claim disputes. Candidates will need to be able to analyze information from several different systems and be able to work in a fast paced Appeals environment. Licensed in MI, NV or IL and/or a compact license.

• 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 a degree from an Accredited School of Nursing or Master’s degree in Behavioral Health or Social Work and 2 – 4 years of related experience.

Knowledge of NCQA, Medicare and Medicaid regulations preferred.

Knowledge of utilization management processes preferred.

License/Certification:

• LPN - Licensed Practical Nurse - State Licensure required or
• LVN - Licensed Vocational Nurse required or
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
• LCSW- License Clinical Social Worker required or
• LMHC-Licensed Mental Health Counselor required or
• LPC-Licensed Professional Counselor required or
• Licensed Marital and Family Therapist (LMFT) required or
• Licensed Psychologist required

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