Senior Clinical Review Nurse - Correspondence

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. ****NOTE: This is a fully remote role. Preference will be given to applicants (1) who reside in either central or mountain time zone USA (2) with an active Florida RN or LPN licensure or a compact RN/LPN credential from another state (3) as well as some of the following: home health, utilization management, determinations, denial letters, and/or leadership experience. Additional Details: • Department: UM Health Support Ops / Florida Medicaid • Business Unit: Centene Corporate • Schedule Options: (1) Sunday-Thursday 12 pm -9 pm CST with 1 hour lunch or (2) Sunday-Wed 11-10 with 1 hour lunch Position Purpose: Drafts correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Audits and revises correspondence letters to ensure they are processed in accordance with Federal, State, and NCQA standards Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Acts as a point of contact for issues and/or questions related to correspondence with the state, local, and federal agencies including third party payers and providers to ensure they are resolved in a timely manner Manages and maintains data needed to identify denial trends and provide results to leadership Monitors and triages cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Provides education to interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards