Clinical Review Clinician_Appeals

Centene Corporation

2d•Remote

About The Position

Centene is a diversified, national organization offering competitive benefits and workplace flexibility. This position is for a Clinical Review Clinician specializing in Appeals, seeking Licensed Vocational Nurses (LVN), Licensed Practical Nurses (LPN), or Registered Nurses (RN) with Medicare Appeals Experience. The role involves performing clinical reviews to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services. This must be done in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. The work schedule is Wednesday - Sunday, 8am to 5pm, with hours accommodating the time zone of residence.

Requirements

LVN, LPN, or RN's with Medicare Appeals Experience
Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
2 – 4 years of related experience
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

Nice To Haves

Knowledge of NCQA, Medicare and Medicaid regulations preferred
Knowledge of utilization management processes preferred

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