Grievance & Appeals Nurse

Centene Corp.; California; Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off and holidays

Flexible remote/hybrid/office options

Job summary

Centene Corp. is seeking a remote RN/LPN/LVN with 2+ years of clinical nursing experience to facilitate medical necessity grievances, appeals and denials. The role requires California licensure and PST hours.

You will review clinical data, prepare case reviews for the Medical Director, and ensure adherence to NCQA guidelines and company policies while improving care and service outcomes.

Qualifications

• Must hold California nursing licensure with 2+ years of clinical nursing experience for RN or 3+ years for LPN/LVN.
• Experience with utilization or appeals review is preferred.
• Knowledge of NCQA guidelines is preferred.

Responsibilities

• Review medical necessity grievances, appeals and denials and disposition letters.
• Review clinical data to determine if criteria are met.
• Prepare case reviews for Medical Director when criteria are not met.
• Identify quality care concerns from grievances and potential issues.
• Provide input into corrective action plans for care and service events.
• Generate appeal resolution communications per policy and NCQA guidelines.
• Maintain NCQA timeframes and appeals database.
• Assist Medical Director with policy revisions to NCQA/contractual requirements.

Skills

Nursing experience

Utilization review

Appeals review

InterQual criteria

Education

LPN/LVN or RN experience

CA RN/LPN/LVN license

Job description

Position Purpose

Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Key Details

Candidate must hold California RN Licensure. This position is remote and will work PST hours.

• Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue cases.
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations
• Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines.
• Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
• May act as liaison between the provider and business to resolve issues
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience

LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification

Current state's RN, LPN, or LVN license.

Must be licensed in CA.

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
• 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