Remote Clinical Appeals Specialist

Centene Management Company LLC; New York (NY); Híbrido; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K & stock plans

Tuition reimbursement

Paid time off & holidays

Flexible work schedules (remote/Hybrid

Descripción de la vacante

Centene Management Company LLC is seeking a fully remote RN-based reviewer to resolve appeals by examining medical records and clinical data for medical necessity in line with NCQA standards. The role prefers NYS licensure (RN/BSN) with CCM or similar certification, and 2+ years in acute care or utilization management related to appeals.

Responsibilities include preparing case reviews for Medical Directors, ensuring timely processing, and communicating results to members, providers, and

Formación

• Requires degree from an accredited nursing program or higher.
• Experience with NCQA/Medicare/Medicaid regulations is preferred.
• Knowledge of NYS Medicaid, Medicare, and Marketplace appeal regulations is preferred.

Responsabilidades

• Prepare case reviews for Medical Directors by researching the appeal and criteria.
• Ensure timely review and response to appeals in line with policies and NCQA standards.
• Communicate with members, providers, and facilities regarding appeals requests; report results.

Conocimientos

RN license

acute care experience

appeals experience

utilization management

NCQA/InterQual knowledge

Educación

BSN or higher

Master's in Behavioral Health or Social Work

Descripción del empleo

Centene Management Company LLC is seeking a fully remote RN-based reviewer to resolve appeals by examining medical records and clinical data for medical necessity in line with NCQA standards. The role prefers NYS licensure (RN/BSN) with CCM or similar certification, and 2+ years in acute care or utilization management related to appeals.

Responsibilities include preparing case reviews for Medical Directors, ensuring timely processing, and communicating results to members, providers, and