Clinical Review Nurse - Correspondence

Transforming the health of the communities we serve, one person at a time Healthcare is best delivered locally Our uniquely local approach allows us to help members access high-quality, culturally sensitive healthcare services. Commited to Corporate Sustainability The health of individuals drives our focus on the environment, removing social barriers to health, and prioritizing responsible corporate governance.

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. 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. Work Schedule: FRI - SAT - SUN - MON from 9am -11pm CST

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 Performs other duties as assigned Complies with all policies and standards