Remote Clinical Appeals Reviewer (RN)

Centene Management Company; New York (NY); Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Management Company is seeking a licensed RN to perform clinical reviews for appeals, examining medical records and data to determine medical necessity in line with NCQA standards. This is a fully remote role, with a preference for an active, unrestricted New York RN license.

The position requires 2+ years in acute care or utilization management or appeals, and knowledge of MCG/InterQual criteria as well as NY Medicaid, Medicare, and Marketplace appeal regulations.

Qualifications

• Active, unrestricted RN license preferred in New York.
• 2+ years of acute care, utilization management or appeals experience.
• Familiarity with MCG/InterQual criteria and NYS Medicaid/Medicare/Marketplace appeal regulations.

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal per state, federal and NCQA standards.
• Communicates with members, providers, facilities and other departments regarding appeals requests.
• Generates appeals resolution communication and reporting per policies and NCQA standards.
• Works with leadership to increase consistency and efficiency of responses to appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Acute care experience

Utilization management

Appeals experience

NCQA/InterQual knowledge

NY Medicaid/Medicare regulations

Education

Nursing degree (RN)

Master’s in Behavioral Health or Social Work

Job description

Centene Management Company is seeking a licensed RN to perform clinical reviews for appeals, examining medical records and data to determine medical necessity in line with NCQA standards. This is a fully remote role, with a preference for an active, unrestricted New York RN license.

The position requires 2+ years in acute care or utilization management or appeals, and knowledge of MCG/InterQual criteria as well as NY Medicaid, Medicare, and Marketplace appeal regulations.