Position Purpose: Perform medical review provider claims, authorizations, and medical records to achieve resolution of authorization issues that result in claims denials or pended claims. Perform retrospective review for medical necessity appeals against medical review criteria to make benefit of determinations.
- Utilize standard methodology and medical criteria sets to analyze and interpret member and/or provider claims, eligibility and quality data.
- Perform retrospective readmission review of hospital and physician claims for admission appropriateness, coding, length of stay, and pricing
- Identify potential process modification, changes, or automation to improve performance, quality, and efficiency
- Manage the review of medical claims, records, and authorizations for billing, coding and other compliance or reimbursement related issues
- Implement and maintain production and quality standards for he medical review process
- Receive and respond to inquiries from Claims, Prior Authorization, and Concurrent Review staff.
- Perform retrospective review of high dollar claims for benefit and pricing-determination
- Maintain departmental records, correspondence and files
- Work collaboratively with Finance to determine appropriateness of pricing
- Assist with other clinical function of medical review
- Graduate from an accredited school of Nursing.
- Advanced degree and/or certification preferred.
- 2+ years in acute care nursing and utilization review.
- Knowledge of Managed care programs and practices required.
- Licensed Registered Nurse
- Certified Professional Coder (CPC)
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.