Remote Utilization Review Nurse – Appeals

Centene Corp.; United States; Remote; USD 37,000 - 67,000; Full time

Benefits offered by this job

Remote work option

Health insurance

401K

Stock purchase plan

Tuition reimbursement

Paid time off

Job summary

Centene Corp. is seeking a fully remote RN to perform clinical reviews for appeals, evaluating medical necessity based on NCQA standards and applicable policies. The role prefers an active NY license and emphasizes utilization management knowledge.

Candidates should have 2+ years in acute care, appeals experience, and familiarity with NY Medicaid/Medicare regulations. Strong communication with members and providers is essential for timely, compliant resolutions.

Qualifications

• Requires RN with active license (and preferred NY license)
• Experience in NCQA, Medicare/Medicaid regulations preferred
• Utilization management/appeals knowledge expected

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable 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

Clinical review

Medical necessity

Communication skills

Time management

Education

Nursing degree

Master's in Behavioral Health

Job description

Centene Corp. is seeking a fully remote RN to perform clinical reviews for appeals, evaluating medical necessity based on NCQA standards and applicable policies. The role prefers an active NY license and emphasizes utilization management knowledge.

Candidates should have 2+ years in acute care, appeals experience, and familiarity with NY Medicaid/Medicare regulations. Strong communication with members and providers is essential for timely, compliant resolutions.