Grievance and Appeals Nurse – State

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🏄 California – Remote

🏄 California – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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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

• Facilitate medical necessity grievances, appeals, and denials, including disposition of denial notification letters • Review clinical information to determine whether medical necessity criteria are met • Review clinical data to determine claim payment based on company policies and NCQA guidelines • Overturn denied claims, uphold denials, and submit cases to the Medical Director for review • Identify potential quality-of-care concerns through member grievance and potential quality issue reviews • Prepare case reviews for the Medical Director when criteria are not met • Identify system improvements and individual care issues affecting appropriate care or service expectations • Provide input into corrective action plans for clinical and service events • Generate appeal resolution communications to members and providers • Create system authorization events for overturned denial decisions • Request additional provider information to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain the appeals process within NCQA timeframes and the appeals turnaround database • Assist the Medical Director with revising, updating, or creating policies to satisfy NCQA and contractual requirements • Act as liaison between providers and the business to resolve issues • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• LPN or LVN with 3+ years of clinical nursing experience • RN with 2+ years of clinical nursing experience • Current state RN, LPN, or LVN license • Must be licensed in California • Experience with utilization or appeals review preferred • Knowledge of InterQual criteria preferred • Ability to work PST hours • Knowledge of company policies and NCQA guidelines

🏖️ Benefits

• Competitive benefits • Competitive pay • Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules