Clinical Review Clinician - Appeals

Centene; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join a leading managed care company as a clinical professional, impacting 28 million members. This role involves clinical reviews and appeals for healthcare services, ensuring compliance with standards. Ideal candidates hold a New York State clinical license and have relevant nursing experience, contributing to quality improvements in healthcare delivery.

Benefits

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Qualifications

• 2 – 4 years of related experience required.
• Must hold relevant state licensure.
• Familiarity with Medicare and Medicaid regulations preferred.

Responsibilities

• Performs clinical reviews to determine medical necessity.
• Communicates with members, providers, and departments regarding appeals.
• Ensures timely response to appeals according to standards.

Skills

Knowledge of NCQA

Utilization management processes

Education

Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing

Job description

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.

Must have a New York State clinical license.

Hours: 8:30am-5pm EST Monday - Friday.

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:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
• LPN - Licensed Practical Nurse - State Licensure required or
• LVN - Licensed Vocational Nurse 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

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.

Must have a New York State clinical license.

Hours: 8:30am-5pm EST Monday - Friday.

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:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
• LPN - Licensed Practical Nurse - State Licensure required or
• LVN - Licensed Vocational Nurse 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: $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

About the company

Centene Corporation is a publicly traded managed care company based in St.

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