Grievance & Appeals Nurse (CA) - Remote Available

You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Review medical necessity grievances, including reviewing clinical information to determine if there was a quality of care or substandard care provided.

May 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

May request additional information, as appropriate from provider(s) to facilitate timely appeals resolution

May gather and prepare case information for Administrative Law Hearings

May 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

Education/Experience:

RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification:

Current CA RN license required.

Benefits 

Our Comprehensive Benefits Package:

Flexible work solutions including remote options, hybrid work schedules and dress flexibility

Competitive pay

Paid Time Off including paid holidays

Health insurance coverage for you and dependents

401(k) and stock purchase plans

Tuition reimbursement and best-in-class training and development