Clinical Review Clinician_Appeals at Centene

**Who this is for** Centene is seeking licensed nurses (LVN, LPN, or RN) with Medicare Appeals experience for a fully remote Clinical Review Clinician role. Thi

Work type: remote

Location: Remote-MD

Salary: $27 – $49/hr

Type: Full-time

Summary

**Who this is for** Centene is seeking licensed nurses (LVN, LPN, or RN) with Medicare Appeals experience for a fully remote Clinical Review Clinician role. This position is ideal for healthcare professionals looking to contribute to medical management and health services. **Key highlights** This role involves performing clinical reviews to resolve appeals by examining medical records and determining medical necessity. You will ensure timely and compliant processing of appeals according to state, federal, and NCQA standards, and communicate with members and providers. **You might be a good fit if you...** - Are a licensed LVN, LPN, or RN with 2-4 years of related experience. - Have specific experience with Medicare Appeals. - Understand NCQA, Medicare, and Medicaid regulations. - Can prepare case reviews, generate resolution communications, and collaborate to improve processes.

Job Description

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 is seeking LVN, LPN, or RN's with Medicare Appeals Experience.Hours are Wednesday - Sunday 8am to 5pm.(hours can accommodate the time zone you reside)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


• This position is seeking LVN, LPN, or RN's with Medicare Appeals Experience.Hours are Wednesday - Sunday 8am to 5pm.(hours can accommodate the time zone you reside)Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.

This position is seeking LVN, LPN, or RN's with Medicare Appeals Experience.Hours are Wednesday - Sunday 8am to 5pm.(hours can accommodate the time zone you reside)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

Pay Range: $27.02 - $48.55 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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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