Remote Clinical Appeals Specialist

Centene Corp.; Kansas; Teletrabalho; USD 70 000 - 95 000; Tempo integral

Resumo da oferta

Centene is hiring two remote Clinical Review Clinician – Appeals Nurses for our Ambetter & MI Medicaid Market. The ideal candidate will have appeals or utilization management experience and proficiency in using company policies and clinical decision based tools such as InterQual to evaluate medical necessity.

Licensure in MI, NV or IL and/or a compact license is preferred. You will review and resolve post-service disputes while ensuring NCQA standards are met in a fast-paced appeals environment.

Qualificações

• 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.

Responsabilidades

• 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.

Conhecimentos

Appeals experience

Utilization management

InterQual knowledge

Healthcare policy

Formação académica

Nursing degree

Master’s in Behavioral Health or Social Work

Ferramentas

InterQual system

EHR systems

Descrição da oferta de emprego

Centene is hiring two remote Clinical Review Clinician – Appeals Nurses for our Ambetter & MI Medicaid Market. The ideal candidate will have appeals or utilization management experience and proficiency in using company policies and clinical decision based tools such as InterQual to evaluate medical necessity.

Licensure in MI, NV or IL and/or a compact license is preferred. You will review and resolve post-service disputes while ensuring NCQA standards are met in a fast-paced appeals environment.