Remote RN: Grievances & Appeals Specialist

Centene; California; Hybrid; CAD 53,000 - 94,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible remote/hybrid/work schedules

Job summary

Centene is seeking a California-licensed nurse (RN or LPN/LVN) for a remote role aligned to Pacific Standard Time hours. You will facilitate medical necessity grievances, appeals, and denials, review clinical data, and determine if criteria are met under NCQA guidelines and company policies.

Responsibilities include overturning denials when appropriate, preparing case reviews for the Medical Director, coordinating with providers, and ensuring timely appeals.

Qualifications

• Must have clinical nursing experience and knowledge of Utilization/Appeals review.
• Knowledge of InterQual criteria preferred.
• Current CA RN/LPN/LVN license required.

Responsibilities

• Review clinical data to determine claim payment based on NCQA guidelines and company policies.
• Overturn denials where criteria are met; uphold denials when appropriate.
• Prepare case reviews for Medical Director when criteria are not met.
• Identify care quality concerns and assist with corrective action plans.
• Generate appeal communications to members and providers per policies.
• Request and gather information from providers to resolve appeals timely.
• Maintain NCQA timeframes and contribute to policy updates.

Skills

Utilization review

Appeals review

Clinical nursing experience

InterQual criteria

Education

RN license (CA)

LPN/LVN license (CA)

Job description

Centene is seeking a California-licensed nurse (RN or LPN/LVN) for a remote role aligned to Pacific Standard Time hours. You will facilitate medical necessity grievances, appeals, and denials, review clinical data, and determine if criteria are met under NCQA guidelines and company policies.

Responsibilities include overturning denials when appropriate, preparing case reviews for the Medical Director, coordinating with providers, and ensuring timely appeals.