Qureos Mentor

Centene Corporation

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 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.
 
 
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 Qualified candidates must be able to work 200PM-1030PM EST.*
 
 
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 Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
 
 
 
 
 Position Purpose
 
 The Senior Pharmacy Resolution Specialist will act as a subject matter expert and handles more complex pharmacy issues and respond to escalated calls from members, provider/physician's offices and pharmacies. This role will make outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
 
 
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 Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
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 Offers options including submission of a prior authorization request
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 Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
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 Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e. additional information requests and medication determination updates)
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 Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards
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 Assists team members often guiding them to the appropriate resolution of more complex and difficult inquiries
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 Participates in the training of less experienced staff, including opportunity for job shadowing
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 Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility
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 Presents proposed solutions in a clear and concise manner
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 Assists with audit preparation as needed
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 Assists with miscellaneous special project work as assigned
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 Performs other duties as assigned
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 Complies with all policies and standards
 
 
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 Education/Experience
 
 High School Diploma / GED.
 
 
 2 years of experience.
 
 
 Call center / customer service experience.
 
 
 Experience in healthcare environment (pharmacy operations, managed care, pharmacy hospitals and or pharmacy retail settings).
 
 
 
 License/Certification
 
 Pharmacy technician certification preferred.
 
 
 Pay Range $19.43 - $32.98 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
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Senior Pharmacy Resolution Specialist

<div>
 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.
 
 
 
 RN Strongly Preferred - Compact RN License Required
 
 
 
 
 100% Remote
 
 
 
 
 Business Hours are 8a - 6p CST. Shifts include one day on the weekend
 
 
 
 
 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.
 
 
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 Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
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 Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
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 Communicates with members, providers, facilities, and other departments regarding appeals requests
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 Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
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 Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
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 Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
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 Performs other duties as assigned
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 Complies with all policies and standards
 
 
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 Education/Experience
 
 Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience.
 
 
 Knowledge of NCQA, Medicare and Medicaid regulations preferred.
 
 
 Knowledge of utilization management processes preferred.
 
 
 
 License/Certification
 
 
 
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 LPN - Licensed Practical Nurse - State Licensure required or
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 LVN - Licensed Vocational Nurse required or
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 RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
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 LCSW- License Clinical Social Worker required or
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 LMHC-Licensed Mental Health Counselor required or
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 LPC-Licensed Professional Counselor required or
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 Licensed Marital and Family Therapist (LMFT) required or
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 Licensed Psychologist required
 
 
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 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
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Clinical Review Clinician - Appeals

Join Centene Corporation and explore 2   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Centene Corporation

About Company

Senior Pharmacy Resolution Specialist

Clinical Review Clinician - Appeals