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 NCQ... more details
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
** Applicants for this role have the flexibility to work remotely from their home anywhere within the state of California.**
Position Purpose: 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
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
- 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
Pay Range: $25.00 - $44.85 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
