You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, youll have access to competitive benefits including a fresh perspective on workplace flexibility.
This position reviews and audits all adverse decisions for members of the health plan while utilizing clinical expertise and specific tools for best practice and compliance. Clinical audits focus on medical and behavioral health utilization denials. Maintains Federal and Local guidelines to meet general accreditation status with regard to denial letters. Writes all denial letters.
Our Comprehensive Benefits Package:
Education/Experience: A High School or GED is required. A Bachelor's Degree in nursing, healthcare or related field is preferred. 2+ years of experience in chart audit, utilization review, case management, clinical claims reviews or relevant position directly related to the position is required. 1+ year of experience in medical and behavioral review is preferred. Ability to provide clearly written feedback that will be used as part of an overall clinical staff remediation process. Knowledge of NCQA, URAC or general accreditation requirements and guidelines for utilization management and denials. knowledge of healthcare delivery. Ability to work independently, multi-task, effectively present information and respond to questions from families, members and providers as well as effectively present information and respond to question from peers and management. Ability to create, review and interpret treatment plans. Demonstrated time management, priority setting skills, problem solving skills as well as interpersonal, verbal, and written communication skills.
License/Certifications: Licensed Practical Nruse (LPN) is required.
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.