Remote Clinical Appeals Specialist

Centene Corp.; New York (NY); 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 plus holidays

Flexible work schedules (remote,hybrid

Job summary

Centene Corp. is seeking a Clinical Review Clinician - Appeals to conduct clinical reviews for appeals, assessing medical necessity from records and data. The role is fully remote but aligned with NY location and Day shift in a full-time schedule.

The ideal candidate will have nursing or behavioral health licensure and 2–4 years of related experience, with knowledge of NCQA standards and interdepartmental collaboration.

Qualifications

• RN license in State or Compact State, or licensed behavioral health professional (LCSW/LMHC/LPC/LMFT/Licensed Psychologist).
• 2-4 years of related experience preferred.

Responsibilities

• Prepare case reviews for Medical Directors by researching the appeal and reviewing applicable criteria.
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeals requests.
• Generate appropriate appeals resolution communication and reporting for members and providers.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to appeals requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures.
• Perform other duties as assigned.
• Comply with all policies and standards.

Education

RN or Master's in Behavioral Health or Social Work

Job description

Centene Corp. is seeking a Clinical Review Clinician - Appeals to conduct clinical reviews for appeals, assessing medical necessity from records and data. The role is fully remote but aligned with NY location and Day shift in a full-time schedule.

The ideal candidate will have nursing or behavioral health licensure and 2–4 years of related experience, with knowledge of NCQA standards and interdepartmental collaboration.