Clinical Review Clinician – Appeals

🔥 14 hours ago

🐊 Florida, Illinois, +15 more states – Remote

🐊 Florida – Remote 🌽 Illinois – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🦀 Maryland – Remote 🚗 Michigan – Remote 🎸 Mississippi – Remote 🔔 Pennsylvania – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote 🍑 Georgia – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

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• Open for 1 day.
• Jobs at this company usually fill in 21 days.
• No salary listed.

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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 in accordance with policies, guidelines, and NCQA standards • Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the basis for appeals • Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards • Communicate with members, providers, facilities, and other departments regarding appeals requests • Generate appropriate appeals resolution communication and reporting for members and providers • Work with leadership to increase the consistency, efficiency, and appropriateness of responses to appeals requests • Partner with interdepartmental teams to improve clinical appeals processes and procedures and prevent recurrences based on industry best practices • Perform other duties as assigned • Comply with all 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 • Licensed in MI, NV or IL and/or a compact license • LPN state licensure required, or LVN licensure required, or RN state and/or compact state licensure required, or LCSW required, or LMHC required, or LPC required, or LMFT required, or Licensed Psychologist required • Knowledge of NCQA, Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred • Proficiency in using company policies and clinical decision-based tools such as InterQual • Ability to analyze information from several different systems • Ability to work in a fast-paced Appeals environment

🏖️ 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

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