Clinical Review Clinician - Appeals - Behavioral Health

About the role

Centene is seeking a clinical professional to join their Medical Management/Health Services team. The position involves performing clinical reviews to resolve and process appeals, ensuring timely responses, and communicating with members and providers.

Responsibilities

• Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and NCQA standards
• 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 appeals 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 RECURRANCES BASED ON INDUSTRY BEST PRACTICES
• Performs other duties as assigned

Requirements

• Required Work Schedule: 8:00 am - 5:00 pm (CST) and a Rotating On-Call schedule
• 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.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of Utilization Management principles and processes preferred.
• Role requires openness, adaptability, and flexibility to business changes, distribution of work, training, and technology processes.
• Strong communication, attention to detail, organizational and time management skills.
• Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone).
• Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams).

License/Certification

• Required: 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
• For Health Net of California: RN license required

Pay

$27.02 - $48.55 per hour

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Qualifications

• Openness, adaptability, and flexibility to business changes, distribution of work, training, and technology processes
• Strong communication, attention to detail, organizational and time management skills
• Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone)
• Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams)