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.Must have a New York State clinical license. Hours: 8:30am-5pm EST Monday – Friday.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 appealEnsures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standardsCommunicates with members, providers, facilities, and other departments regarding appeals requestsGenerates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standardsWorks with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requestsPartners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practicesPerforms other duties as assignedComplies with all policies and standardsEducation/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing 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 orLVN – Licensed Vocational Nurse required orRN – Registered Nurse – State Licensure and/or Compact State Licensure required orLCSW- License Clinical Social Worker required orLMHC-Licensed Mental Health Counselor required orLPC-Licensed Professional Counselor required orLicensed Marital and Family Therapist (LMFT) required orLicensed Psychologist requiredPay Range: $26.50 – $47.59 per hourCentene 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

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