Clinical Review Clinician - Appeals

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.
 

NOTE: Candidates must be fully licensed with one of the approved license/certifications listed below upon the submission of the Centene application.

Required Work Schedule: 8:00 am - 5:00 pm (CST) and a Rotating On-Call schedule

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 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

Required Education/Experience:

• Requires Graduate from an Accredited School of Nursing or

• Master's degree in related Behavioral/Counseling field AND minimum of 2 – 4 years of related experience

Preferred Experience:

• 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred.

• Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred.

• Knowledge of NCQA, Medicare and Medicaid regulations preferred.

• Knowledge of Utilization Management principles and processes preferred

• Role requires openness, adaptability, and flexibility to business changes, distribution of work, training, and technology processes

• Strong communication, attention to detail, organizational and time management skills

• Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone)

• Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams)

License/Certification - Required:

• 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

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.

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