What are the responsibilities and job description for the Clinical Review Nurse - Correspondence position at Dev?
Company Description
Jobs for Humanity is partnering with Centene to build an inclusive and just employment ecosystem. Therefore, we prioritize individuals coming from the following communities: Refugee, Neurodivergent, Single Parent, Blind or Low Vision, Deaf or Hard of Hearing, Black, Hispanic, Asian, Military Veterans, the Elderly, the LGBTQ, and Justice Impacted individuals. This position is open to candidates who reside in and have the legal right to work in the country where the job is located.
Company Name: Centene
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.
Oklahoma Complete Health, a Centene company, is committed to providing quality healthcare solutions to transform the health of Oklahomans.
At Oklahoma Complete Health, we are community advocates and change-makers in search of an inclusive culture grounded by our commitment to work-life balance, competitive compensation, and continuous career development. Join us and be a part of a collaborative, growing network of innovative thinkers delivering solutions at the local level.
Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.
- 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
- Contributes to correspondence letter template creation and maintenance with the correspondence team
- 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
- Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
- Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
- Coordinates with 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
Education/Experience: Requires a Bachelor's degree or graduate from an Accredited School of Nursing and 2 – 4 years of related experience.
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
- LPN - Licensed Practical Nurse - State Licensure required
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
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.
