Clinical Review Clinician - Appeals

Oklahoma Complete Health; Town of Texas (WI); Remote; Full time

Job summary

A leading health organization is seeking a Clinical Review Clinician to manage and resolve appeals related to medical necessity. The successful candidate will perform clinical reviews, communicate effectively with stakeholders, and ensure compliance with relevant standards including NCQA. Candidates should possess nursing qualifications and relevant experience.

Benefits

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Qualifications

• Requires 2-4 years of related experience.
• License as LPN, LVN, or RN is required.
• Knowledge of NCQA and utilization management preferred.

Responsibilities

• Performs clinical reviews to resolve appeal cases.
• Communicates with members, providers, and other departments.
• Prepares case reviews and ensures timely processing.

Skills

Knowledge of NCQA

Knowledge of Medicare regulations

Knowledge of Medicaid regulations

Utilization management processes

Education

Graduate from an Accredited School of Nursing

Bachelor’s degree in Nursing

Job description

Clinical Review Clinician - Appeals page is loaded

Clinical Review Clinician - Appeals

Apply locations Remote-TX time type Full time posted on Posted 2 Days Ago job requisition id 1574821

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.

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:

• 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.

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 , 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

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About Us

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.