Submission for the position: Senior Clinical Appeals Review Nurse - (Job Number: 1327009)
https://centene.taleo.net/careersection/jobdetail.ftl?job=1327009&lang=en
Senior Clinical Appeals Review Nurse
You could be the one who changes everything for our 26 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Conducts appeal reviews for outpatient procedures and/or behavioral health cases utilizing established guidelines and member plan benefits. Responsible for preparing cases for physician review and all appeal related activities accurately, efficiently, and within mandated timeline requirements. Communicates the outcome of the appeals process with members, internal and external partners. Serves as a subject matter expert (SME) for the appeals department. Assists the department management with precepting / training Clinical Appeals Review Nurses, resolving workflow problems, monitoring department inventory, and handling escalated issues. Candidate Education: * Required A High School or GED
• Essential Functions: * Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations.
• * Reviews moderately complexed appeal cases for diagnosis codes and medical necessity to support the outpatient procedure and/or behavioral health case.
• * Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action towards appeal.
• * Applies regulatory requirements and accreditation standards to all review activity and reporting.
• * Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems.
• * Prepares and submit projects, reports or assignments as needed to meet department initiatives and/or objectives.
• * Produces approval & denial letters on behalf of the Medical Director for submission to member, provider or hospital.
• * Ensure quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing.
• * Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies.
• * Assists management with monitoring clinical appeal review inventory to include resolving workflow problems and identifying continuous improvement opportunities. Reviews clinical files for urgent/emergent status and assigns to clinical appeals staff.
• * Acts as a subject matter expert (SME) within the department. Handles escalated issues and will address questions from clinical appeals staff.
• * Serves as a preceptor to new team members and assists in training all members of the clinical appeals team. Leads daily huddles with clinical appeals staff, as needed.
• * Performs department and clinical audits at the request of department management. Identifies and reports quality of care issues.
• * Performs other duties as assigned Additional Responsibilities:
Our Comprehensive Benefits Package:
• Flexible work solutions including remote options, hybrid work schedules and dress flexibility
• Competitive pay
• Paid Time Off including paid holidays
• Health insurance coverage for you and dependents
• 401(k) and stock purchase plans
• Tuition reimbursement and best-in-class training and development
**RN/LPN Compact Preferred**
* Preferred A Bachelor's Degree in a related field Candidate Experience: * Required 4 years of experience in a clinical setting with general nursing exposure in UM to include pre-authorization, utilization review, concurrent review, discharge planning, CM w/review, and/or skilled nursing facility reviews.
* Required 2 years of experience in an acute care clinical setting (Medical and/or Behavioral Health)
* Preferred 4 years of experience in managed care Licenses and Certifications:A license in one of the following is required: Required Other Requires one of the following: LPN, LSW, LCSW, LMHC, or RN
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.
Medical Management
USA-Florida-Tampa
USA-Georgia-Remote - GA, USA-South Carolina-Remote - SC, USA-Kentucky-Remote - KY
WellCare of KY
Schedule: Full-time Location(s): USA-Florida-Tampa