Clinical Review Clinician - Appeals (Remote)

About the role

Centene is hiring two remote Clinical Review Clinician - Appeals nurses for its Ambetter and Michigan Medicaid market. The role reviews medical records and clinical data to determine medical necessity for services, in line with company policies, guidelines and NCQA standards. It involves researching and reviewing provider post-service claim disputes in a fast-paced appeals environment.

Key responsibilities

• Prepare case reviews for Medical Directors by researching the appeal, reviewing applicable criteria and analyzing the basis of the appeal
• Ensure timely review, processing and response to appeals in line with state, federal and NCQA standards
• Communicate with members, providers, facilities and other departments about appeals requests
• Generate appeals resolution communications and reporting for members and providers
• Work with leadership to make appeals responses more consistent, efficient and appropriate
• Partner with interdepartmental teams to improve clinical appeals processes and prevent recurrences
• Perform other duties as assigned and comply with all policies and standards

Required profile

• Degree from an accredited school of nursing or a master's degree in behavioral health or social work, with 2-4 years of related experience
• Licensed in Michigan, Nevada or Illinois, or holds a compact license; LPN, LVN, RN, LCSW, LMHC, LPC, LMFT or licensed psychologist
• Appeals or utilization management experience preferred

Required skills

• Proficiency with clinical decision-making tools such as InterQual
• Ability to analyze information from several systems and work quickly in a fast-paced appeals environment
• Knowledge of NCQA, Medicare and Medicaid regulations and utilization management processes preferred

What we offer

• Competitive pay, health insurance, 401K and stock purchase plans
• Tuition reimbursement and paid time off plus holidays
• Flexible schedule options: remote, hybrid, field or office