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 be licensed in California. Will work on PST hours.
Position Purpose:
Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met
Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue cases.
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations
Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines.
Create system authorization events for overturned denial decisions
Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
Gather and prepare case information for Administrative Law Hearings
Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
May act as liaison between the provider and business to resolve issues
Performs other duties as assigned
Complies with all policies and standards
Education/Experience:
LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.
License/Certification: Current state's RN, LPN, or LVN license.
Must be licensed in California.
Location: Position is remote. Will work PST hours.
Pay Range: $27.02 - $48.55 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
Centene Corporation is a diversified, national healthcare organization serving 28 million members across the United States. The company operates multiple state health plans, including Fidelis, and focuses on transforming community health through managed care services. Centene provides comprehensive healthcare management services including medical necessity reviews, prior authorization processes, cost containment initiatives, and fraud, waste, and abuse prevention programs. The organization emphasizes quality care delivery and cost-effectiveness while maintaining regulatory compliance with Medicare, Medicaid, and state-specific healthcare requirements.
