Grievance and Appeals Nurse (State)

Centene
California
Workplace: RemoteFull timeUSD 27.02 - 48.55 hourlyFunction: Healthcare (Clinical, Medical, Wellness)Skills: ["Attention to detail","Case management","Communication"]

Facilitate medical-necessity grievances, appeals, and denials by reviewing clinical information against medical necessity criteria and NCQA guidelines. Evaluate cases for claim payment determinations, prepare materials for Medical Director review and Administrative Law Hearings, and generate member/provider resolution communications. Identify quality-of-care concerns, support corrective action input, and maintain appeal timelines and databases while serving as a liaison when needed.

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FursaFursa
Centene
Centene
1 day ago

Grievance and Appeals Nurse (State)

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Source: Company careers pageValidated by: Fursa AI
Last checked: 11 hours agoStatus: Live

Job Summary

Facilitate medical-necessity grievances, appeals, and denials by reviewing clinical information against medical necessity criteria and NCQA guidelines. Evaluate cases for claim payment determinations, prepare materials for Medical Director review and Administrative Law Hearings, and generate member/provider resolution communications. Identify quality-of-care concerns, support corrective action input, and maintain appeal timelines and databases while serving as a liaison when needed.
Location: California
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)

Key Responsibilities

  • •Facilitate medical necessity grievances, appeals, and denials, including disposition of denial notification letters.
  • •Review clinical data to determine claim payment per company policies and NCQA guidelines, including overturning denied claims.
  • •Prepare case review materials for the Medical Director and create appeal resolution communications for members and providers.
  • •Identify potential quality care concerns by reviewing grievances and potential quality issue cases, and provide input for corrective action plans.
  • •Maintain appeals processes within NCQA timeframes and support requests for additional information, Administrative Law Hearings, and policy updates.

Pay and Benefits

Salary: USD 27.02 - 48.55 hourly
Perks:Health Insurance401kEquity

Key Requirements

  • •Must be a current licensed RN, LPN, or LVN in California.
  • •RN: 2+ years of clinical nursing experience; LPN/LVN: 3+ years of clinical nursing experience.
  • •Experience with utilization or appeals review is preferred.
  • •Knowledge of InterQual criteria is preferred.
Experience:UtilizationAppeals
Skills:Attention to detailCase managementCommunication
Licenses:RNLPNLVNCalifornia license

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn