Top 539 Health Net Jobs

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- Full-time
- Remote
- LMFT
- Nursing
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Corporate Ethics & Compliance Investigator
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Inpatient Utilization Review Clinician, Behavioral Health
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Senior Compliance Investigator
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SIU Investigator
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Supervisor, Behavioral Health Utilization Management
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Manager, Sales Investigations
Centene —New York, NY
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SIU Investigator
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Senior Director, Clinical Data Science
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SIU Investigator
Centene —Ohio
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Supervisory Medical Director, National Physical Health Appeals Outpatient UM
Centene —New York, NY
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Associate Actuary - Medicaid
Centene —New York, NY
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Vice President, Provider Engagement
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Senior Compliance Corrections Specialist
Centene —Missouri
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Actuary
Centene —New York, NY
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Senior Adversarial Emulation - Red Team Operator
Centene —New York, NY
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Senior Actuarial Analyst
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4d

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Clinical Review Clinician - Appeals - Behavioral Health

Centene -
Ohio

Apply Now

Job Details

Full-time
$27.02 - $48.55 an hour
4 days ago

Benefits

Paid holidays
Health insurance
401(k)
Tuition reimbursement
Paid time off

Qualifications

Research

Full Job Description

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.

NOTE: Candidates must be fully licensed with one of the approved license/certifications listed below upon the submission of the Centene application.

Required Work Schedule: 8:00 am - 5:00 pm (CST) and a Rotating On-Call schedule

Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned
Complies with all policies and standards

Required Education/Experience:

Requires Graduate from an Accredited School of Nursing or
Master's degree in related Behavioral/Counseling field AND minimum of 2 – 4 years of related experience

Preferred Experience:

6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred.
Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of Utilization Management principles and processes preferred
Role requires openness, adaptability, and flexibility to business changes, distribution of work, training, and technology processes
Strong communication, attention to detail, organizational and time management skills
Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone)
Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams)

License/Certification - Required:

RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
LCSW- License Clinical Social Worker required or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Marital and Family Therapist (LMFT) required or
Licensed Psychologist required
For Health Net of California: RN license required

Pay Range: $27.02 - $48.55 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

Apply Now

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Senior Actuarial Analyst

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