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.
Responsibilities
- 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 consistency, efficiency, and appropriateness of responses of all appeals requests
- PARTNERS WITH INTERDEPARTMENTAL TEAMS TO IMPROVE CLINICAL APPEALS PROCESSES AND PROCEDURES TO PREVENT RECURRANCES BASED ON INDUSTRY BEST PRACTICES
- Performs other duties as assigned
Required Education/Experience
- Requires Graduate from an Accredited School of Nursing OR
- Master's degree in related Behavioral/Counseling field AND minimum of 2 – 4 years of related experience
Preferred Experience
- 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred.
- Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred.
- Knowledge of NCQA, Medicare and Medicaid regulations preferred.
- Knowledge of Utilization Management principles and processes preferred
License/Certification
- Licensed Practical Nurse (LPN) - State Licensure required
- Licensed Vocational Nurse (LVN) - State Licensure required
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
- LCSW - License Clinical Social Worker required
- LMHC - Licensed Mental Health Counselor required
- LPC - Licensed Professional Counselor required
- LMFT - Licensed Marital and Family Therapist (LMFT) required
- Licensed Psychologist required
- For Health Net of California: RN license required
Benefits
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.
About the Role
Centene offers a diverse and inclusive environment where employees are encouraged to bring their whole selves to work. We are committed to providing a safe and respectful workplace for all employees and are dedicated to fostering an environment free from discrimination and harassment. We value the unique contributions each employee brings to our organization and strive to create a culture of inclusion and belonging.