Appeals Nurse

Centene Corporation Linthicum Heights , MD 21090

Posted 2 months ago

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: LPN with 3 years of clinical nursing experience or 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.

License/Certification: RN or LPN license.

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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Appeals Nurse

Centene Corporation