Remote CA RN: Grievance & Appeals Nurse

Centene Corp.; Sacramento (CA); Remote; USD 37,000 - 67,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off

Flexible remote/hybrid/work schedules

Job summary

Centene Corp. in California is seeking a remote nurse reviewer to facilitate medical necessity grievances, appeals, and denials. The role requires an active CA RN/LPN/LVN license and PST hours for remote work.

You will review clinical data, overturn or uphold denials per NCQA guidelines, and prepare case materials for Medical Director review, while identifying care concerns and supporting improvement actions within NCQA timelines.

Qualifications

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

Responsibilities

• Review clinical data to determine claim payment based on company policies and 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

Skills

Clinical nursing experience

Utilization review

Appeals review

InterQual criteria

Education

Nursing license (LPN/LVN or RN)

Job description

Centene Corp. in California is seeking a remote nurse reviewer to facilitate medical necessity grievances, appeals, and denials. The role requires an active CA RN/LPN/LVN license and PST hours for remote work.

You will review clinical data, overturn or uphold denials per NCQA guidelines, and prepare case materials for Medical Director review, while identifying care concerns and supporting improvement actions within NCQA timelines.