Remote Grievance & Appeals Nurse (CA RN)

Centene Corp.; EE. UU.; A distancia; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off

Flexible work arrangements

Descripción de la vacante

Centene Corp. in California seeks a remote nurse reviewer to handle medical necessity grievances, appeals and denials. The role requires CA RN/LPN/LVN licensure and 2+ years of clinical nursing experience, with NCQA and InterQual knowledge preferred.

You will review cases, prepare submissions for the Medical Director, and ensure NCQA-compliant communication with members and providers. Flexible schedules and PST alignment support this essential function.

Formación

• LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience.
• Experience with utilization or appeals review preferred.
• Knowledge of InterQual criteria preferred.

Responsabilidades

• Review clinical data to determine claim payment based on company policies and NCQA guidelines.
• Overturn denied claims or uphold denials and submit cases for Medical Director review.
• Identify quality care concerns by reviewing member grievances and potential issues.
• Prepare case reviews for Medical Director when criteria are not met.
• Identify system improvements affecting care or service delivery.
• Provide input into corrective action plans for clinical and service events.
• Generate appeal resolution communications to members and providers per policy.

Conocimientos

Clinical nursing experience

Appeals review

NCQA guidelines knowledge

InterQual criteria knowledge

Communication skills

Educación

RN license required

LPN/LVN license

3+ years nursing experience (LPN/LVN)

2+ years nursing experience (RN)

Utilization/appeals review experience preferred

Herramientas

EMR systems

Case management software

Descripción del empleo

Centene Corp. in California seeks a remote nurse reviewer to handle medical necessity grievances, appeals and denials. The role requires CA RN/LPN/LVN licensure and 2+ years of clinical nursing experience, with NCQA and InterQual knowledge preferred.

You will review cases, prepare submissions for the Medical Director, and ensure NCQA-compliant communication with members and providers. Flexible schedules and PST alignment support this essential function.