Lead Clinical Review Nurse

hace 2 meses

Gualaceo Centene Corporation Full time$35 - $64

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.
 

Location: Position is remote. Prefer candidate to live in PST time zone.

Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST.

Position Purpose: Oversees 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.

  • Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards
  • Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards
  • Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations
  • Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner
  • Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner
  • Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics
  • Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management
  • Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
  • Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends
  • Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices
  • Provides guidance, subject matter expertise and training as needed
  • Performs other duties as assigned
  • Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 5 – 7 years of related experience.

Expert knowledge of Medicare and Medicaid regulations preferred.
Expert knowledge of utilization management processes preferred.

License/Certification:

  • LPN - Licensed Practical Nurse - State Licensure required- Compact License

Location: Position is remote. Prefer candidate to live in PST time zone.

Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST.

Pay Range: $ $63.79 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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.


Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

  • Lead Clinical Review Nurse

    hace 2 meses

    Gualaceo Centene Corporation Full time$35 - $64

    You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. · ...

  • Clinical Review Nurse

    hace 6 días

    Gualaceo Centene Corporation Full time$27 - $49

    You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. · ...

  • Clinical Review Nurse

    hace 2 semanas

    Gualaceo Centene Corporation Full time$27 - $49

    You could be the one who changes everything for our members as a clinical professional on our Medical Management/Health Services team. · ...

  • Clinical Review Nurse

    hace 2 meses

    Gualaceo Centene Corporation Full time$27 - $48

    You could be the one who changes everything for our members as a clinical professional on our Medical Management/Health Services team. · ...

  • Clinical Review Nurse

    hace 1 mes

    Gualaceo Centene Corporation Full time$27 - $48

    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. ...

  • Clinical Review Nurse

    hace 1 mes

    Gualaceo Centene Corporation Full time$27 - $48

    You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. · ...

  • Clinical Review Nurse

    hace 1 mes

    Gualaceo Centene Corporation Full time$27 - $48

    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 ...

  • Appeals Nurse

    hace 4 semanas

    Gualaceo Centene Corporation Full time$27 - $48

    You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. · ...

  • Utilization Review Clinician

    hace 4 semanas

    Gualaceo Centene Corporation Full time$27 - $48

    Can change everything for our members as a clinical professional on Medical Management/Health Services team. · Evaluates member's treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate. · P ...

  • Complex Discharge Planner

    hace 4 semanas

    Gualaceo Centene Corporation Full time$27 - $49

    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. · ...

  • Utilization Review Clinician

    hace 2 meses

    Gualaceo Centene Corporation Full time$27 - $48

    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. ...

  • Provider Quality Liaison

    hace 1 mes

    Gualaceo Centene Corporation Full time$19 - $32

    You could be the one who changes everything for our 28 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 fl ...

  • Data Analyst III

    hace 3 semanas

    Cárdenas Centene Corporation Full time$70.100 - $126.200

    You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. · We are seeking a Data Analyst who is a strong communicator and enjoys presenting, creating visuals, and helping the team tell a c ...

  • Care Navigator Pregnancy Postpartum LPN

    hace 6 días

    Debant Centene Corporation Full time$23 - $39

    You could be the one who changes everything for our members. Develops, assesses and coordinates care management activities based on member needs to provide quality cost effective healthcare outcomes. · ...

  • Utilization Management Nurse Consultant

    hace 2 meses

    Gualaceo CVS Health Full time$26 - $69

    +As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more conven ...

  • Remote Mortgage Loan Officer

    hace 4 días

    Gualaceo Zillow Full time$11 - $24

    This is an opportunity to grow your career as a Mortgage Loan Officer in a fast-paced, phone-based sales environment. · You'll originate purchase mortgage loans using company-provided digital leads, guiding customers from first contact through funding. · ...

  • Care Manager

    hace 1 semana

    Gualaceo Centene Corporation Full time$56.200 - $101.000

    You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. · Must Reside in Nevada. · Remote Care Manager – Behavioral Health | Nevada Medicaid | Centene ...

  • Premier Loan Officer

    hace 2 semanas

    Gualaceo Zillow Full time$11 - $24

    We're at the forefront of revolutionizing the home financing experience. · ...

  • Premier Loan Officer

    hace 1 semana

    Gualaceo Zillow Full time$12 - $25

    As a Premier Loan Officer you're not just originating mortgages — you're building a network within the fastest-growing channel in the industry. · ...

  • Senior Manager, Health Care Quality

    hace 1 semana

    Gualaceo CVS Health Full time$75.400 - $165.954

    Care for people where when and how they choose in a way that is uniquely more connected convenient and compassionate. · ...

  • Data Analyst III

    hace 1 mes

    Cárdenas Centene Corporation Full time$68.700 - $123.700

    You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. · We are seeking a Data Analyst who is a strong communicator and enjoys presenting, creating visuals, and helping the team tell a c ...