Clinical Review Specialist
4 weeks ago
We are seeking a highly skilled Clinical Review Clinician to join our Medical Management/Health Services team. As a key member of our team, you will play a critical role in resolving and processing 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.
Key Responsibilities- Perform clinical reviews to resolve and process appeals by reviewing medical records and clinical data.
- 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.
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 – 4 years of related experience.
- Knowledge of NCQA, Medicare and Medicaid regulations preferred.
- Knowledge of utilization management processes preferred.
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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