RN Clinical Review Clinician - Appeals - Remote CA

Centene • Full-time • Remote • $26.50 - $47.59 / hour • 3w ago

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.

This position requires RN California Licensure and for candidates to have a minimum of 1 year UM experience as well as be able to work M-F 8-5 PST Hours.

Position Purpose: 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

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.

Knowledge of NCQA, Medicare and Medicaid regulations preferred.

Knowledge of utilization management processes preferred.

License/Certification:

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
For Health Net of California: RN license required

Pay Range: $26.50 - $47.59 per hour

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. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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