Appeals NurseJanet Rangi
Centene’s founding values and beliefs are central to our company’s success. From our beginnings as a single Medicaid plan in Milwaukee, Centene has grown into a Fortune 500, multi-national health solutions enterprise, employing over 32,000 people and serving 12.3 million beneficiaries.
With more than 30 years of experience in operating government-sponsored programs, Centene remains committed to the health and unique needs of the communities we serve. Our decentralized structure of state-based health plans allows Centene to ensure that members, providers, contractors and regulators have direct involvement with a local CEO.
In addition to being the largest Medicaid Managed Care Organization in the country, we are proud to be the largest carrier on the Health Insurance Marketplace and a national leader in managed long-term services and supports. Our work with both the TRICARE and Veterans Choice programs has positioned Centene as one of the nation’s largest providers of managed care services for military families and veterans. Through all our efforts, we hold firm to our belief that every individual deserves access to quality healthcare with dignity.
As Centene has grown, we have never lost our focus on the individual. We have built a portfolio of health solutions that allow us to provide effective and accessible healthcare. Our Envolve family of specialty companies help deliver a full spectrum of care from physical health to emotional wellness. Meanwhile, cutting edge research and insights from the Envolve Center for Health Behavior Change TM – a unique partnership between Centene, the Brown School at Washington University in St. Louis, and the Center for Advanced Hindsight at Duke University – is showing us new ways to affect positive change in the millions of individuals we serve.
Each day, our employees bring their diverse ideas, unique experiences and cultures to work, helping Centene create innovative programs and health solutions that distinguish us from others in healthcare.
|Job Category||Healthcare, Nursing|
|Professional Qualifications||RN or LPN license|
|Previous Experience||LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience.|
|Responsibilities||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.|