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Clinical Review Clinician - Appeals - Remote

Posted 2 days ago
Healthcare
Full Time
USA
26.50 - 47.59 USD/hour

Overview

This position involves performing clinical reviews to resolve and process appeals by analyzing medical records and clinical data in accordance with established guidelines.

In Short

  • Perform clinical reviews for appeals processing.
  • Review medical records and clinical data for medical necessity.
  • Prepare case reviews for Medical Directors.
  • Ensure timely processing of appeals in compliance with standards.
  • Communicate with members and providers regarding appeals.
  • Generate appeals resolution communication.
  • Work with leadership to improve appeals processes.
  • Comply with all policies and standards.
  • Requires a nursing degree and relevant experience.
  • Knowledge of NCQA, Medicare, and Medicaid regulations preferred.

Requirements

  • Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
  • 2 – 4 years of related experience.
  • RN - Registered Nurse - State Licensure required.
  • Knowledge of utilization management processes preferred.

Benefits

  • Competitive pay.
  • Health insurance.
  • 401K and stock purchase plans.
  • Tuition reimbursement.
  • Paid time off plus holidays.
  • Flexible work schedules including remote options.
Centene Management Company logo

Centene Management Company

Centene Management Company LLC is a diversified national organization dedicated to transforming the health of communities by providing high-quality healthcare solutions to its 28 million members. With a focus on building strong partnerships between health plans and provider networks, Centene emphasizes optimal performance in care delivery, quality improvement, and cost utilization. The company values diversity and offers a comprehensive benefits package, including competitive pay, flexible work arrangements, and support for employee development. Centene is committed to helping individuals and families live healthier lives through innovative programs and a wide range of health solutions.

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