Clinical Review Nurse - Correspondence at Centene

**Who this is for** This opportunity is for a Registered Nurse with a strong understanding of clinical review processes and experience in drafting correspondenc

Work type: remote

Salary: $27 – $49/hr

Type: Full-time

Summary

**Who this is for** This opportunity is for a Registered Nurse with a strong understanding of clinical review processes and experience in drafting correspondence. If you are adept at interpreting clinical documentation, applying NCQA standards, and contributing to efficient denial management, this role is an excellent match. **Key highlights** As a Clinical Review Nurse, you will be instrumental in drafting clear and accurate correspondence letters based on review outcomes, ensuring compliance with NCQA standards. You will conduct thorough clinical reviews of documentation, investigate denials, and collaborate with interdepartmental teams to enhance clinical processes and procedures. **You might be a good fit if you...** - Are a Graduate from an Accredited School of Nursing or hold a Bachelor's degree in Nursing with 2-4 years of related experience. - Have experience in prior authorization, concurrent review, or utilization review. - Are knowledgeable in clinical documentation review, denial investigation, and applying NCQA standards. - Possess strong communication and analytical skills, with the ability to coordinate with various teams and provide feedback for process improvement.

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.

Position Purpose: 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

# This is a remote position.Candidates must reside in the Central or Eastern time zones.

# Work Schedule:Monday through Friday10:00 AM – 6:30 PM CST or 11:00 AM – 7:30 PM EST

# The ideal candidate will have prior experience in prior authorization, concurrent review, or utilization review.

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

License/Certification:

LPN - Licensed Practical Nurse - State Licensure required and

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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