Clinical Review Clinician - Appeals

Centene; New York (NY); A distancia; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules (remote,hybrid

Descripción de la vacante

Centene Corp. is seeking a Clinical Review Clinician - Appeals to conduct clinical reviews for appeals, assessing medical necessity from records and data. The role is fully remote but aligned with NY location and Day shift in a full-time schedule.

The ideal candidate will have nursing or behavioral health licensure and 2–4 years of related experience, with knowledge of NCQA standards and interdepartmental collaboration.

Formación

• RN license in State or Compact State, or licensed behavioral health professional (LCSW/LMHC/LPC/LMFT/Licensed Psychologist).
• 2-4 years of related experience preferred.

Responsabilidades

• Prepare case reviews for Medical Directors by researching the appeal and reviewing applicable criteria.
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeals requests.
• Generate appropriate appeals resolution communication and reporting for members and providers.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to appeals requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures.
• Perform other duties as assigned.
• Comply with all policies and standards.

Educación

RN or Master's in Behavioral Health or Social Work

Descripción del empleo

About This Role

The Clinical Review Clinician - Appeals performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data to determine medical necessity for services. This fully remote position is ideal for candidates with experience in acute care and utilization management.

Highlights

• Pay: $27.02 - $48.55 per hour
• Location: Remote, NY
• Schedule: Full Time, Day shift

What You'll Do

• Prepare case reviews for Medical Directors by researching the appeal and reviewing applicable criteria.
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeals requests.
• Generate appropriate appeals resolution communication and reporting for members and providers.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to appeals requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements

Education:

• Degree from an Accredited School of Nursing or Master's degree in Behavioral Health or Social Work required.

Experience

• 2 - 4 years of related experience preferred.

Licenses & Certifications

• 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
• LMFT (Licensed Marital and Family Therapist) - required, OR
• Licensed Psychologist - required.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules (remote, hybrid, field, or office work)

About Centene

Centene is a leading healthcare provider committed to delivering exceptional patient care. They connect people to the care they need to live healthier lives, making a real impact every day through meaningful challenges that support individuals, families, and communities.