Grievance & Appeals Nurse

Centene Corporation•Remote-CA, CA

1d•$27 - $49•Remote

About The Position

Facilitate medical necessity grievances, appeals, and denials, including disposition of denial notification letters and review of clinical information to determine whether medical necessity criteria are met. This is a remote position working PST hours, and the candidate must hold California RN licensure. The nurse reviews clinical data to determine claim payment based on company policies and NCQA guidelines, recognizes potential quality-of-care concerns, and prepares cases for Medical Director review when criteria are not met. The role also supports corrective action plans, communicates appeal resolutions to members and providers, creates authorization events for overturned denials, gathers information for Administrative Law Hearings, and maintains appeals within required NCQA timeframes. Candidates must have a current California license as an RN, LPN, or LVN and meet the applicable clinical nursing experience requirement. Experience with utilization or appeals review and knowledge of InterQual criteria are preferred. The listed pay range is $27.02–$48.55 per hour.

Requirements

Current California RN, LPN, or LVN license; the posting specifically states the candidate must be licensed in California.
LPN or LVN candidates must have at least 3 years of clinical nursing experience, or RN candidates must have at least 2 years of clinical nursing experience.
Work remotely during PST hours.

Nice To Haves

Experience with utilization or appeals review.
Knowledge of InterQual criteria.

Responsibilities

Review clinical data to determine claim payment based on company policies and NCQA guidelines, including overturning or upholding denials and submitting cases to the Medical Director for review.
Recognize potential quality-of-care concerns by reviewing member grievances and potential quality issue cases.
Prepare cases for Medical Director review when criteria are not met based on additional clinical information received.
Identify system improvements or individual care issues that result in inappropriate care or failure to meet service expectations.
Provide input into corrective action plans for clinical and service events to improve decision-making and quality of care and services.
Generate appeal resolution communications to members and providers in accordance with company policies and NCQA guidelines.
Create system authorization events for overturned denial decisions.
Request additional information from providers as appropriate to facilitate timely appeal resolution.
Gather and prepare case information for Administrative Law Hearings.
Maintain the appeals process within prescribed NCQA timeframes and maintain the appeals turnaround database.
Assist the Medical Director with revising, updating, or creating policies to satisfy NCQA and contractual requirements.
Act as a liaison between providers and the business to resolve issues, as needed.
Perform other duties as assigned.
Comply with all policies and standards.