You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
This position requires NY RN Licensure. Daily responsibilities include researching medical history and preparing legal documents to be submitted to court. UM/Case Management experience highly preferred as well as excellent writing capabilities.
**Position Purpose:** Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met
+ Review clinical data to determine claim payment based on company policies and
+ National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
+ Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
+ Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
+ Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
+ Gather and prepare case information for Administrative Law Hearings
+ Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
+ Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.
**Education/Experience:** NYS RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.
**For Fidelis Care only:** NYS RN license required.
Pay Range: $25.97 - $46.68 per hour
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.
...Job Description Job Title: Content Marketing Specialist Location: USA - Remote. Upstate... ...Internet Marketing Ninjas, a leading digital marketing agency since 1999 and Best Places... ...our clients. We will train you - No experience is necessary . The average content...
Position: SAP Security ConsultantLocation : Wilmington, DE (Onsite)Hire Type: ContractRole & Responsibilities:Good knowledge in defining and Troubleshooting User Authorizations.Should have worked in User Monitoring Activities from Audit perspectiveGood Security...
...Chief Sales Officer About the Company Well-established foodservice equipment, supply & design company Industry Food Production Type Privately Held About the Role The Company is in search of a Chief Sales Officer (CSO) with a proven track record...
...High paying CRNA opening about 1hr from Albuquerque, NM: M-F 7-3pm shift until room closes unless on call. Call 1:3. Every third weekend call (17 weeks off per year) Inpatient and outpatient Case type is general surgery, OB/GYN (Avg. 15 deliveries per month...
...different career where you can meet new people, travel, and get paid? We provide training on how to draw blood (phlebotomy). No experience is needed (you just need to like people!) A quick overview of a day in the life: You would arrive at our Hays location....