Centene Corporation Linthicum Heights , MD 21090
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.