Remote Grievance & Appeals Nurse (CA RN/LVN)

Centene Management Company LLC; California; Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Management Company LLC is seeking a nurse to facilitate medical necessity grievances, appeals and denials while reviewing clinical data to determine if criteria are met. The role requires California RN/LPN licensing and supports remote work with PST hours.

Responsibilities include preparing case reviews for the Medical Director and generating appeal communications to members and providers, ensuring NCQA timeframes are met and updating the appeals database as needed.

Qualifications

• 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.

Responsibilities

• Facilitate medical necessity grievance, appeals and denials.
• Review clinical data to determine if criteria are met.
• Prepare case reviews for Medical Director when criteria are not met.
• Generate appeal resolution communications to member and provider.
• Maintain NCQA timeframes and appeals turnaround database.

Skills

Nursing experience

Appeals review

InterQual knowledge

Education

LPN/LVN or RN with clinical nursing experience

Job description

Centene Management Company LLC is seeking a nurse to facilitate medical necessity grievances, appeals and denials while reviewing clinical data to determine if criteria are met. The role requires California RN/LPN licensing and supports remote work with PST hours.

Responsibilities include preparing case reviews for the Medical Director and generating appeal communications to members and providers, ensuring NCQA timeframes are met and updating the appeals database as needed.