- 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 the 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
- LPN - Licensed Practical Nurse - State Licensure required or
- LVN - Licensed Vocational Nurse required or
- 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
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Care Review Clinician, Inpatient Review
1 day ago
Molina Healthcare Los Angeles, United States**NIGHT SHIFT WORK SCHEDULE:** · **_PERMANENT SHIFT WILL BE A 12 hour NIGHT SHIFT: 7:30PM (in the evening) - 08:30AM (in the morning) PACIFIC HOURS , 3 days a week will rotate. This department runs 24 / 7 / 365 days a year. Rotating weekends and holidays will be required._** **_C ...
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Mental Health Clinical Program Supervisor
6 days ago
Balance Treatment Center Calabasas, United StatesJob Description · Job DescriptionSalary: · ABOUT US: · Balance Treatment Programs are leading the way in comprehensive mental health care. Our mission is to improve the lives of individuals and their families by addressing the issues that are preventing growth. We strive to ensu ...
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LVN, Supervisor
1 week ago
UnitedHealth Group West Hills, United StatesFor those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start **Caring. Connecting. Growing together.** · Optum's Pacific West region is redefining ...
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Occupational Therapist
4 days ago
Select Physical Therapy West Hills, United StatesOverview · Select Physical Therapy is seeking an outpatient Occupational Therapist (Ortho, Lymphedema) in Tarzana, CA · Our Tarzana outpatient therapy center continues to expand, and we are seeking a compassionate and driven licensed occupational therapist to provide exceptional ...
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Program Coordinator
1 week ago
CSUN -The University Corporation Northridge, United StatesAbout The University Corporation · The University Corporation is a non-profit auxiliary corporation providing commercial and administrative services to California State University, Northridge. Our mission is to provide services and solutions that address the needs of California S ...
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Nurse Practitioner- PRN/Part Time
1 week ago
Matrix Medical Network Northridge, CA, United States TemporaryOverview: Nurse Practitioner – PRN/Part Time Home Risk Assessments About Us: Matrix Medical Network offers a broad range of clinical services and proven expertise that give primary care providers and the at-risk health plan members we visit with every day the tools and knowledge ...
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Clinical Data Audit Consultant
1 month ago
Centene Corporation Woodland Hills, United States Full timeYou 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. ...
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Clinic Director Outpatient Mental Health
1 week ago
Ellie Mental Health - 246 Los Angeles, United StatesJob Description · Job DescriptionCompensation & BenefitsSalary range: $120,000 - $150,000 annually · Health, dental, vision insurance · 401(k) · Paid time off · Annual holidays · Flexible work environment - you manage your workday · Position Overview · As a Clinic Director at Ell ...
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Travel Physical Therapist
3 weeks ago
Healthcare Pros, Inc. West Hills, CA, United StatesHealthcare Pros, Inc. is seeking a travel Physical Therapist for a travel job in West Hills, California. · Job Description & Requirements · Specialty: Physical Therapist · Discipline: Therapy · Start Date: 06/17/2024 · Duration: 13 weeks · 40 hours per week · Shift: 8 hours, days ...
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Mental Health Clinical Program Supervisor
5 days ago
Balance Treatment Center Calabasas, United States**ABOUT US**: · Balance Treatment Programs are leading the way in comprehensive mental health care. Our mission is to improve the lives of individuals and their families by addressing the issues that are preventing growth. We strive to ensure our programs remain responsive to the ...
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Occupational Therapist
2 weeks ago
Select Physical Therapy Tarzana, CA, United StatesSelect Physical Therapy is seeking an outpatient Occupational Therapist (Ortho, Lymphedema) in Tarzana, CA · Our Tarzana outpatient therapy center continues to expand, and we are seeking a compassionate and driven licensed occupational therapist to provide exceptional patient ca ...
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Occupational Therapist
2 weeks ago
Select Physical Therapy Tarzana, CA, United StatesOverview: Select Physical Therapy is seeking an outpatient Occupational Therapist (Ortho, Lymphedema) in Tarzana, CA Our Tarzana outpatient therapy center continues to expand, and we are seeking a compassionate and driven licensed occupational therapist to provide exceptional pa ...
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Medical Scribe
1 week ago
CEDARS-SINAI Tarzana, United States**Are you ready to bring your skills to a world-class healthcare organization recognized as one of the top ten in the United States? Do you have a passion for the highest quality and patient happiness? Then please respond to this dynamic opportunity available with one of the best ...
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Rn Oncology Supervisor
1 week ago
CEDARS-SINAI Tarzana, United StatesThe Supervisor, Clinical Operations Oncology RN is responsible for supervising the clinical staff and clinical operations of the Oncology department by performing the following duties personally or through assigned personnel. The Supervisor is expected to manage the overall unit, ...
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Radiology - Radiologic Tech
3 weeks ago
Trusted Health Los Angeles, United States Full timeTrusted is seeking an experienced allied health professional for this exciting travel assignment. Trusted has streamlined the travel experience by enabling clinicians to apply directly to jobs without the need for recruiters. This unique approach provides more transparency, elimi ...
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RN - Trauma Clinical Program Coordinator Days
3 weeks ago
Providence Mission Hills, United StatesDescription · RN - Trauma Clinical Program Coordinator at Providence Holy Cross Medical Center in Mission Hills, CA. · As a Magnet Designated Hospital, our nurses are highly engaged and involved in Shared Governance driving practice changes. Our nurses are supported to advance th ...
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Infection Preventionist Nurse
1 week ago
Magnolia Gardens Skilled Nursing Facility Granada Hills, CA, United States Full timeWe are seeking to hire an IP Nurse to join our team We are a skilled nursing facility looking for dynamic associates to join our clinical team and provide our residents with a best-in-class care experience Whether you are just starting your career or have years of experience we w ...
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Registered Nurse II, Oncology
2 weeks ago
CEDARS-SINAI SANTA MONICA, United StatesJob Description · The Clinical Nurse II, Oncology (per diem) is a Registered Nurse who delivers direct care to assigned Oncology patients in an ambulatory setting. Nursing care is delivered using standards of care by following approved policies and procedures. Applying appropriat ...
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RN Clinical Supervisor
1 week ago
Neogen Care Sherman Oaks, CA, United States Full time* Join Our Team of Highly Talented and Committed Clinical Professionals * This is an exciting opportunity for an upwardly achieving Registered Nurse with management and supervisory experience to take the next level in their career. Neogen Care is a will established Home Health Ca ...
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Physician Billing Coordinator
1 week ago
CEDARS-SINAI SANTA MONICA, United StatesJob Description · The Physician Billing Coordinator III performs all duties related to registration and the gathering of insurance and eligibility information. · Job Duties and Responsibilities: · Completes all charge tickets and turns into PBS on a timely basis. Ensures that all ...
Clinical Review Clinician - Woodland Hills, United States - Centene Corporation
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.
** Applicants for this role have the flexibility to work remotely from their home anywhere within the state of California.**
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.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 – 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
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. Total compensation may also include additional forms of incentives.
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.
