Remote Clinical Appeals Reviewer (RN/Utilization Mgmt)

Centene Corporation; Oregon; Hybride; USD 37 000 - 67 000; Plein temps

Avantages offerts par ce poste

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work arrangements (remote/hyb

Résumé du poste

Centene Corporation is seeking a fully remote RN appeals reviewer to support processing of medical necessity reviews for appeals. You will research medical records and apply NCQA standards to determine appropriate resolutions.

The role prefers an active RN license (New York State license preferred), a BSN or CCM, and 2+ years in acute care, utilization management, or appeals. Familiarity with MCG/InterQual criteria and Medicaid/Medicare regulations is advantageous.

Qualifications

• Requires a degree from an Accredited School of Nursing or Master's degree in Behavioral Health or Social Work.
• 2–4 years of related experience in acute care, utilization management, or appeals.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Licenses: RN, LPN/LVN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist.

Responsabilités

• Prepares case reviews for Medical Directors by researching the appeal and reviewing applicable criteria.
• Ensures timely review and response to appeals in line with state, federal and NCQA standards.
• Communicates with members, providers, facilities, and departments regarding appeals requests.
• Generates appeal resolution communications and reporting per company policies and NCQA standards.
• Works with leadership to improve consistency, efficiency, and appropriateness of responses.
• Partners with interdepartmental teams to improve clinical appeals processes and prevent recurrences.
• Performs other duties as assigned.
• Complies with all policies and standards.

Connaissances

RN license

Healthcare experience

Formation

Accredited School of Nursing

Master's degree in Behavioral Health or Social Work

Description du poste

Centene Corporation is seeking a fully remote RN appeals reviewer to support processing of medical necessity reviews for appeals. You will research medical records and apply NCQA standards to determine appropriate resolutions.

The role prefers an active RN license (New York State license preferred), a BSN or CCM, and 2+ years in acute care, utilization management, or appeals. Familiarity with MCG/InterQual criteria and Medicaid/Medicare regulations is advantageous.