Join Centene's Medical Management/Health Services team as a Senior Clinical Appeals Specialist and make a meaningful difference in the lives of our 28 million members! As a vital member of our nationwide organization, you will leverage your clinical expertise to facilitate the appeals process for medical necessity denials, ensuring fair and accurate healthcare access. This is a remote position based in Florida, offering a flexible work environment and a competitive salary. If you are a dedicated and experienced Registered Nurse (RN) or Licensed Practical Nurse (LPN) with a passion for patient advocacy and a strong understanding of healthcare regulations, we encourage you to apply.
Job Highlights:
- Position: Senior Clinical Appeals Specialist
- Company: Centene
- Location: Remote (Florida Residents Only)
- Start Date: Immediate Openings Available
- Compensation: Competitive Salary ($25.97 - $46.68 per hour)
About Centene:
Centene is a leading national healthcare company committed to delivering comprehensive and innovative healthcare solutions. We are a diversified organization dedicated to improving the health and well-being of our members. We foster a supportive and inclusive work environment that values flexibility and employee growth. Our commitment to workplace flexibility extends to our remote work options, allowing you to thrive in a work-life balance that suits your needs.
Position Purpose:
The Senior Clinical Appeals Specialist plays a critical role in ensuring equitable access to healthcare services for our members. You will be responsible for the comprehensive review and management of medical necessity appeals and denials, utilizing your clinical judgment and knowledge of regulatory guidelines to advocate for our members' needs. This role involves a high degree of autonomy and requires strong analytical, communication, and problem-solving skills. You will be a key contributor to our team's success in upholding quality care standards and ensuring compliance with national guidelines.
Key Responsibilities:
- Medical Necessity Appeals Review: Thoroughly review medical records, clinical documentation, and supporting evidence to determine the medical necessity of denied or disputed services. Apply your clinical expertise to evaluate whether the services meet established medical necessity criteria, including Medicare, Medicaid, and company-specific policies.
- Denial Disposition & Communication: Make informed decisions regarding the disposition of denied claims, including the preparation and distribution of denial notification letters. Ensure clear, concise, and empathetic communication with members and providers regarding appeal outcomes.
- Regulatory Compliance: Adhere to National Committee for Quality Assurance (NCQA) guidelines and other relevant regulatory requirements in the appeals process. This includes the ability to overturn denied claims when appropriate, uphold denials when medically justified, and submit cases to the Medical Director for review when necessary.
- Medical Director Support: Prepare comprehensive case reviews and summaries for the Medical Director, highlighting key clinical information and recommendations for decision-making in complex or ambiguous cases.
- Communication & Collaboration: Generate professional and informative appeal resolution communications for members and providers, ensuring compliance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions. Proactively communicate with providers to request additional information needed to facilitate timely appeals resolution.
- Administrative Law Hearings: Gather and meticulously prepare all necessary case information for Administrative Law Hearings, ensuring accurate and complete documentation to support member appeals.
- Process Improvement & Policy Support: Maintain the appeals process within prescribed NCQA timeframes and utilize the appeals turnaround database to track progress and identify areas for improvement. Assist the Medical Director with reviewing, updating, and/or creating new policies to ensure compliance with NCQA and contractual requirements.
- Quality Assurance: Contribute to quality assurance initiatives by identifying trends in denials and appeals, and recommending strategies to improve clinical documentation and prevent future denials.
- Utilization Review Support: Collaborate with utilization review teams to ensure consistency in medical necessity determinations and to identify opportunities for process optimization.
Qualifications:
- Education & Experience: Licensed Practical Nurse (LPN) with a minimum of 3 years of clinical nursing experience, or Registered Nurse (RN) with a minimum of 2 years of clinical nursing experience.
- Technical Skills: Proficient in Microsoft Office applications (Word, Excel, Outlook).
- Preferred Experience: Experience with utilization review or appeals review processes is highly preferred. Knowledge of InterQual criteria is strongly preferred.
- Licensure: Valid and active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the State of Florida is required.
- Behavioral Health Experience: Experience in behavioral health settings is a plus.
- Availability: Must be available for Saturday shifts.
Benefits:
Centene offers a comprehensive benefits package designed to support your well-being and professional growth. This includes a competitive salary range of $25.97 - $46.68 per hour, comprehensive health insurance, a 401K plan with company match, stock purchase plans, tuition reimbursement, paid time off and holidays, and a flexible work environment with remote, hybrid, field, or office work options. Your actual compensation will be determined based on your skills, experience, education, and other job-related factors as permitted by law. Additional incentives may also be available.
Commitment to Diversity:
Centene is an equal opportunity employer committed to diversity and inclusion. We value the unique perspectives and experiences of all our employees. 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 any other characteristic protected by applicable law.
We Encourage You to Apply!
Even if you don't meet every qualification, we encourage you to apply! We are looking for talented and dedicated individuals to join our friendly and supportive team. Apply today and be a part of a company that is making a difference in the lives of millions.
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