Remote Appeals Nurse: Clinical Review Specialist

Centene Corp.; Kentucky; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Remote/hybrid/field or office work

Job summary

Centene Corp. is seeking two remote Clinical Review Clinician – Appeals Nurses to support the Ambetter & MI Medicaid Market.

The role requires reviewing medical records and clinical data to determine medical necessity per NCQA standards and company policies. The ideal candidate will have appeals or utilization management experience and licensure in MI, NV, IL, or a compact license, with 2–4 years of related experience and an accredited nursing degree or a Master's in Behavioral Health or Social

Qualifications

• 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.

Responsibilities

• 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.

Skills

Appeals experience

Utilization management

InterQual knowledge

NCQA standards familiarity

Communication skills

Education

Bachelors/ Nursing degree

Master’s in Behavioral Health or Social Work

Tools

InterQual

Job description

Centene Corp. is seeking two remote Clinical Review Clinician – Appeals Nurses to support the Ambetter & MI Medicaid Market.

The role requires reviewing medical records and clinical data to determine medical necessity per NCQA standards and company policies. The ideal candidate will have appeals or utilization management experience and licensure in MI, NV, IL, or a compact license, with 2–4 years of related experience and an accredited nursing degree or a Master's in Behavioral Health or Social