Clinical Review Clinician - Appeals

Centene Management Company; New York (NY); Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Management Company is seeking a licensed RN to perform clinical reviews for appeals, examining medical records and data to determine medical necessity in line with NCQA standards. This is a fully remote role, with a preference for an active, unrestricted New York RN license.

The position requires 2+ years in acute care or utilization management or appeals, and knowledge of MCG/InterQual criteria as well as NY Medicaid, Medicare, and Marketplace appeal regulations.

Qualifications

• Active, unrestricted RN license preferred in New York.
• 2+ years of acute care, utilization management or appeals experience.
• Familiarity with MCG/InterQual criteria and NYS Medicaid/Medicare/Marketplace appeal regulations.

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal per state, federal and NCQA standards.
• Communicates with members, providers, facilities and other departments regarding appeals requests.
• Generates appeals resolution communication and reporting per policies and NCQA standards.
• Works with leadership to increase consistency and efficiency of responses to appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Acute care experience

Utilization management

Appeals experience

NCQA/InterQual knowledge

NY Medicaid/Medicare regulations

Education

Nursing degree (RN)

Master’s in Behavioral Health or Social Work

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: This fully remote, Monday–Friday position strongly prefers an active, unrestricted New York State RN license; a BSN and CCM or other utilization management certification are also preferred. Candidates should have 2+ years of acute care experience, utilization management or appeals experience, and working knowledge of MCG/InterQual criteria and NYS Medicaid, Medicare, and Marketplace appeal regulations.

• 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

Pay Range: $27.02 - $48.55 per hour

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