Clinical Review Clinician - Appeals - Behavioral Health
About The Position
As a clinical professional on our Medical Management/Health Services team, you will play a crucial role in changing outcomes for our members. Centene is a diversified, national organization that offers competitive benefits and a fresh perspective on workplace flexibility. This position involves performing clinical reviews to resolve and process appeals by examining medical records and clinical data to determine medical necessity for services, ensuring compliance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. You will prepare case reviews for Medical Directors, research appeals, review applicable criteria, and analyze the basis for the appeal. A key responsibility is ensuring timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards. You will also communicate with members, providers, facilities, and other departments regarding appeals requests, and generate appropriate appeals resolution communication and reporting. This role involves collaborating with leadership to enhance the consistency, efficiency, and appropriateness of appeal responses and partnering with interdepartmental teams to improve clinical appeals processes and procedures based on industry best practices. Other duties as assigned and compliance with all policies and standards are also expected.
Requirements
- Requires Graduate from an Accredited School of Nursing or Master's degree in related Behavioral/Counseling field AND minimum of 2 – 4 years of related experience.
- 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.
- For Health Net of California: RN license required.
- Candidates must be fully licensed with one of the approved license/certifications listed above upon the submission of the Centene application.
- Strong communication, attention to detail, organizational and time management skills.
- Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone).
- Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams).
Nice To Haves
- 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred.
- Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred.
- Knowledge of NCQA, Medicare and Medicaid regulations preferred.
- Knowledge of Utilization Management principles and processes preferred.
- Role requires openness, adaptability, and flexibility to business changes, distribution of work, training, and technology processes.
Responsibilities
- 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.
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- a flexible approach to work with remote, hybrid, field or office work schedules.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
