Clinical Review Clinician - Appeals

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.

Key Details: Centene is hiring two remote Clinical Review Clinician – Appeals Nurses for our Ambetter & MI Medicaid Market. The ideal candidate will have appeals or utilization management experience and proficiency in using company policies and clinical decision based tools such as InterQual to evaluate medical necessity. This position will include researching and reviewing Provider Post-Service Claim disputes. Candidates will need to be able to analyze information from several different systems and be able to work in a fast paced Appeals environment. Licensed in MI, NV or IL and/or a compact license.

• 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.

Education/Experience: Requires a degree from an Accredited School of Nursing or Master's degree in Behavioral Health or Social Work and 2 – 4 years of related experience.

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

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