Clinical Review Clinician – Appeals

🔥 5 minutes ago

🗽 New York – Remote

🗽 New York – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

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

• Perform clinical reviews needed to resolve and process appeals • Review medical records and clinical data to determine medical necessity according to policies, guidelines, and NCQA standards • Prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing appeal bases • Ensure timely review, processing, and response to appeals according to State, Federal, and NCQA standards • Communicate with members, providers, facilities, and other departments regarding appeal requests • Generate appeals resolution communications and reporting for members and providers • Work with leadership to improve consistency, efficiency, and appropriateness of appeal responses • Partner with interdepartmental teams to improve clinical appeals processes and prevent recurrences • Perform other assigned duties and comply with policies and standards

🎯 Requirements

• Degree from an Accredited School of Nursing or Master’s degree in Behavioral Health or Social Work • 2–4 years of related experience • 2+ years of acute care experience • Utilization management or appeals experience • Working knowledge of MCG/InterQual criteria • Knowledge of NYS Medicaid, Medicare, and Marketplace appeal regulations • RN - Registered Nurse - State Licensure and/or Compact State Licensure required, or LCSW, LMHC, LPC, LMFT, Licensed Psychologist, or equivalent listed license required • Knowledge of NCQA, Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity

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