Clinical Review Clinician Appeals RN

Centene Corporation•Remote-CA, CA

1d•$27 - $49•Remote

About The Position

Centene is seeking an RN for their Medical Management/Health Services team to perform clinical reviews for appeals. This remote role requires an RN licensed in CA with a background in hospital-based adult and pediatric care, familiar with current rules and regulations. The position involves reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and NCQA standards. The RN will prepare case reviews for Medical Directors, ensure timely processing of appeals, and communicate with members, providers, and facilities. This role also involves generating resolution communications and reporting, collaborating with leadership to improve appeal processes, and partnering with interdepartmental teams to enhance clinical appeals procedures based on industry best practices. Other duties as assigned and compliance with all policies and standards are expected.

Requirements

Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
2 – 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
For Health Net of California: RN license required.
Licensed to work in CA.

Nice To Haves

Background in hospital based adult and pediatric care.
Familiar with current rules and regulations.

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.