Remote Grievance & Appeals Nurse – CA RN

Centene Corp.; California; Híbrido; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off and holidays

Flexible remote/hybrid/office options

Descripción de la vacante

Centene Corp. is seeking a remote RN/LPN/LVN with 2+ years of clinical nursing experience to facilitate medical necessity grievances, appeals and denials. The role requires California licensure and PST hours.

You will review clinical data, prepare case reviews for the Medical Director, and ensure adherence to NCQA guidelines and company policies while improving care and service outcomes.

Formación

• Must hold California nursing licensure with 2+ years of clinical nursing experience for RN or 3+ years for LPN/LVN.
• Experience with utilization or appeals review is preferred.
• Knowledge of NCQA guidelines is preferred.

Responsabilidades

• Review medical necessity grievances, appeals and denials and disposition letters.
• Review clinical data to determine if criteria are met.
• Prepare case reviews for Medical Director when criteria are not met.
• Identify quality care concerns from grievances and potential issues.
• Provide input into corrective action plans for care and service events.
• Generate appeal resolution communications per policy and NCQA guidelines.
• Maintain NCQA timeframes and appeals database.
• Assist Medical Director with policy revisions to NCQA/contractual requirements.

Conocimientos

Nursing experience

Utilization review

Appeals review

InterQual criteria

Educación

LPN/LVN or RN experience

CA RN/LPN/LVN license

Descripción del empleo

Centene Corp. is seeking a remote RN/LPN/LVN with 2+ years of clinical nursing experience to facilitate medical necessity grievances, appeals and denials. The role requires California licensure and PST hours.

You will review clinical data, prepare case reviews for the Medical Director, and ensure adherence to NCQA guidelines and company policies while improving care and service outcomes.