Join our team of clinical professionals at Centene, a leading national organization, and make a difference in the lives of our 28 million members. As an Appeals Nurse, you will play a vital role in our Medical Management/Health Services team, utilizing your clinical expertise to facilitate medical necessity appeals and denials.
Job Highlights:
- Remote/work-from-home position with a competitive salary ($25.97 - $46.68 per hour)
- Immediate openings available, with a required Saturday shift
- Comprehensive benefits package, including health insurance, 401K, and tuition reimbursement
- Flexible approach to work, with a focus on work-life balance
- Opportunity to work with a diverse and dynamic team, with a commitment to diversity and inclusion
Position Purpose:
As an Appeals Nurse, you will be responsible for reviewing clinical data to determine claim payment, overturning denied claims, and upholding denials. You will also prepare case reviews for the Medical Director, generate appeal resolution communication, and maintain the appeals process within prescribed timeframes.
Key Responsibilities:
- Review clinical information to determine if medical necessity criteria are met
- Prepare case reviews for the Medical Director, including overturning denied claims and upholding denials
- Generate appeal resolution communication to members and providers, in accordance with company policies and NCQA guidelines
- Maintain appeals process within prescribed NCQA timeframes and appeals turnaround database
- Assist the Medical Director with revising, updating, and creating new policies to satisfy NCQA and contractual requirements
Requirements:
- LPN with 3+ years of clinical nursing experience, or RN with 2+ years of clinical nursing experience
- Proficient with Microsoft Office applications, with experience in utilization or appeals review preferred
- Knowledge of InterQual criteria preferred, with a required FL RN or LPN license
- Behavioral Health experience preferred
What We Offer:
- Competitive pay and comprehensive benefits package
- Opportunity to work with a diverse and dynamic team, with a commitment to diversity and inclusion
- Flexible approach to work, with a focus on work-life balance
- Tuition reimbursement, paid time off, and holidays
How to Apply:
If you are a motivated and experienced clinical professional, looking to make a difference in the lives of our members, please apply now. We encourage you to apply, even if you don't feel like a perfect match, as we are looking for great people to join our friendly team.
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