Clinical Review Nurse - Correspondence

Centene Corporation

2d • $27 - $49 • Remote

About The Position

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. Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards This is a remote position. Candidates must reside in the Central or Eastern time zones. Work Schedule: Monday through Friday 10:00 AM – 6:30 PM CST or 11:00 AM – 7:30 PM EST The ideal candidate will have prior experience in prior authorization, concurrent review, or utilization review.

Requirements

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• LPN - Licensed Practical Nurse - State Licensure required

Nice To Haves

• The ideal candidate will have prior experience in prior authorization, concurrent review, or utilization review.

Responsibilities

• Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards
• Works with senior management to identify and implement opportunities for improvement
• Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
• Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees