Clinical Review Nurse - Correspondence

Centene Corporation

1d•Hybrid

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. The position drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards and works with senior management to identify and implement opportunities for improvement.

Requirements

RN or LPN/LVN Compact License Required
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
For Superior Plan: RN license

Nice To Haves

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

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