Clinical Review Clinician – Appeals

🔥 20 minutes ago

🐊 Florida, Iowa, +2 more states – Remote

🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🤠 Texas – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

✨ Clinician

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards • 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

🎯 Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing • 2 – 4 years of related experience • Knowledge of NCQA, Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred • LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required

🏖️ Benefits

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work