Location: Tulsa, OK
Nurse for the Ambetter line of business. The ideal candidate will have Appeals or Utilization Management experience and have knowledge of Inter Qual criteria. 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 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 Education/Experience: Requires a Bachelor's degree or graduate from an Accredited School of Nursing and 2
– 4 years of related experience.
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: 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 Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
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, interaction, interactionual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. For more details: jobs-search. org/insurance_tulsa-c443982/clinical-review-clinician-appeals-tulsa_i1973749292
Insurance jobs are positions in the insurance industry where professionals help individuals and businesses manage risk and protect against financial loss. They encompass a variety of roles such as insurance agents, underwriters, claims adjusters, and actuaries. Key characteristics of these jobs include assessing risk, determining policy terms, negotiating contracts, and assisting clients with claims. Insurance careers often require strong analytical skills, attention to detail, and excellent interpersonal communication. These roles are crucial for the functioning of a stable economy as they provide a safety net for unforeseen events.
state of practice EKG certification is recommended and/or a special test may be required, NIHSS (stroke scale) is also recommended Specialty-related certifications are preferred and may be required for specific positions Experience as a Telemetry RN in a hospital setting Minimum of 2 years of experience as an RN Job Details Weekly Pay: $1,848 per week Location: Tulsa, OK Shift Schedule: Nights Assignment Duration: 13 Weeks Weekly Hours: 36 Hours Agency Benefits Day 1 Health Insurance (Medical, Dental, Vision), Flexible Housing Options, Guaranteed Stipend: Facility Cancelled Shifts, JACHO Certified, Prestigious Facilities, PTO Program, Weekly Pay, Paid Compliance Cost, Referral Bonuses, Extra Shift Bonuses, 401(k) Plan For more details: jobs-search.
org/insurance_tulsa-c443982/job_i1971120537
state of practice EKG certification is recommended and/or a special test may be required, NIHSS (stroke scale) is also recommended Specialty-related certifications are preferred and may be required for specific positions Experience as a Telemetry RN in a hospital setting Minimum of 2 years of experience as an RN Job Details Weekly Pay: $1,715 per week Location: Tulsa, OK Shift Schedule: Nights Assignment Duration: 13 Weeks Weekly Hours: 36 Hours Agency Benefits Day 1 Health Insurance (Medical, Dental, Vision), Flexible Housing Options, Guaranteed Stipend: Facility Cancelled Shifts, JACHO Certified, Prestigious Facilities, PTO Program, Weekly Pay, Paid Compliance Cost, Referral Bonuses, Extra Shift Bonuses, 401(k) Plan For more details: jobs-search.
org/insurance_tulsa-c443982/job_i1971044859
state of practice EKG certification is recommended and/or a special test may be required, NIHSS (stroke scale) is also recommended Specialty-related certifications are preferred and may be required for specific positions Experience as a Telemetry RN in a hospital setting Minimum of 2 years of experience as an RN Job Details Weekly Pay: $1,828 per week Location: Tulsa, OK Shift Schedule: Nights Assignment Duration: 13 Weeks Weekly Hours: 36 Hours Agency Benefits Day 1 Health Insurance (Medical, Dental, Vision), Flexible Housing Options, Guaranteed Stipend: Facility Cancelled Shifts, JACHO Certified, Prestigious Facilities, PTO Program, Weekly Pay, Paid Compliance Cost, Referral Bonuses, Extra Shift Bonuses, 401(k) Plan For more details: jobs-search.
org/insurance_tulsa-c443982/job_i1969454422
