Remote Utilization Review Nurse – Appeals

Centene Corporation; New York (NY); Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote work with flexible schedules

Job summary

Centene Corporation is seeking a fully remote Appeals Nurse Reviewer to conduct clinical reviews of medical records and data to determine medical necessity under NCQA standards. The role supports NY-state regulatory considerations and operates Monday–Friday from a fully remote setting.

Requirements include an active NY RN license (BSN preferred), 2+ years in acute care or utilization management, and knowledge of NCQA and NY Medicaid/Medicare regulations.

Qualifications

• Must hold an active, unrestricted New York State RN license; BSN preferred.
• CCM or other utilization management certification preferred.
• 2+ years acute care experience; utilization management or appeals experience.
• Knowledge of NCQA standards and NYS Medicaid, Medicare, and Marketplace appeal regulations.
• Licenses/certifications list: LPN/LVN/RN/LCSW/LMHC/LPC/LMFT/License Psychologist as applicable.

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal, reviewing criteria, and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicates with members, providers, facilities, and other departments regarding appeals requests.
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

RN license

NCQA knowledge

Utilization management

Appeals experience

Acute care experience

MCG/InterQual criteria knowledge

Education

BSN

MS in Behavioral Health or Social Work

Job description

Centene Corporation is seeking a fully remote Appeals Nurse Reviewer to conduct clinical reviews of medical records and data to determine medical necessity under NCQA standards. The role supports NY-state regulatory considerations and operates Monday–Friday from a fully remote setting.

Requirements include an active NY RN license (BSN preferred), 2+ years in acute care or utilization management, and knowledge of NCQA and NY Medicaid/Medicare regulations.