Clinical Review Specialist

21 hours ago


Jefferson City, Missouri, United States Centene Corporation Full time
Job Title: Clinical Review Clinician

Join Centene Corporation, a leading healthcare company, as a Clinical Review Clinician. In this role, you will play a critical part in ensuring the quality and integrity of our medical management and health services team.

Job Summary:

We are seeking a highly skilled and experienced Clinical Review Clinician to join our team. As a Clinical Review Clinician, you will be responsible for performing clinical reviews to resolve and process appeals. You will review medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Key Responsibilities:
  • Prepare case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
  • Ensure timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
  • Communicate with members, providers, facilities, and other departments regarding appeals requests
  • Generate appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
  • Work with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
  • Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
  • Perform other duties as assigned
  • Comply with all policies and standards
Requirements:

We require a Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2-4 years of related experience. Knowledge of NCQA, Medicare and Medicaid regulations is preferred. Knowledge of utilization management processes is also preferred.

License/Certification:

We require LPN - Licensed Practical Nurse - State Licensure, LVN - Licensed Vocational Nurse, RN - Registered Nurse - State Licensure and/or Compact State Licensure, LCSW- License Clinical Social Worker, LMHC-Licensed Mental Health Counselor, LPC-Licensed Professional Counselor, Licensed Marital and Family Therapist (LMFT), or Licensed Psychologist.

Compensation and Benefits:

We offer 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.

Equal Opportunity Employer:

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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