Clinical Review Nurse

5 days ago

Tampa, Florida, United States Centene Corporation Full time

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.

** Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Florida. Expected work schedule is 1 - 10pm EST, Monday - Friday with some holidays required.**

Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

  • Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
  • Contributes to correspondence letter template creation and maintenance with the correspondence team
  • Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
  • Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
  • Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
  • Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
  • Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
  • Performs other duties as assigned
  • Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 – 4 years of related experience.

Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:

  • LPN - Licensed Practical Nurse - State Licensure required
Pay Range: $ $46.68 per hour

Centene 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. Total compensation may also include additional forms of incentives.

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.

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