Clinical Review Clinician - Appeals

Centene Corporation • Remote-NY, NY

7d • $27 - $49 • Remote

About The Position

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. This is a fully remote, Monday–Friday position. The role prepares case reviews for Medical Directors, supports timely and compliant processing of appeals, communicates with members and providers, and contributes to improvements in appeals processes. A degree from an accredited School of Nursing or a master’s degree in Behavioral Health or Social Work and 2–4 years of related experience are required. An applicable professional license is required. An active, unrestricted New York State RN license, a BSN, and CCM or another utilization management certification are strongly preferred. The pay range is $27.02–$48.55 per hour.

Requirements

• Degree from an accredited School of Nursing or a master’s degree in Behavioral Health or Social Work.
• 2–4 years of related experience.
• One of the following licenses is required: RN (State Licensure and/or Compact State Licensure), LCSW, LMHC, LPC, LMFT, or Licensed Psychologist.
• Candidates should have 2+ years of acute care experience, utilization management or appeals experience, and working knowledge of MCG/InterQual criteria and New York State Medicaid, Medicare, and Marketplace appeal regulations.

Nice To Haves

• Active, unrestricted New York State RN license strongly preferred.
• BSN preferred.
• CCM or another utilization management certification preferred.
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the basis for each appeal.
• Ensure timely review, processing, and responses to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeal requests.
• Generate appropriate appeals resolution communications and reporting for members and providers in accordance with company policies and State, Federal, and NCQA standards.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to appeals requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures and prevent recurrences based on industry best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Benefits

• Competitive pay
• Health insurance
• 401(k)
• Stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work schedules, including remote, hybrid, field, or office work, subject to role and eligibility

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level