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.
 
 
 
 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

<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.
 
 
 
 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.
 
 
 
 
 This is a hybrid role with 40-50% travel required to local pharmacies. Qualified candidates must reside in Kentucky.
 
 
 
 
 Position Purpose
 
 
 
 Primary liaison between internal and external (e.g. Providers and pharmacies) teams to advance pharmacy quality (Part D Patient Safety Measures, HEDIS, PQA, etc.) performance. This position will own a territory and will work closely with strategist(s), trainer(s) pharmacy quality performance manager(s), and health plan partners. Through consistent relationship building, critical thinking and problem solving, this role will strengthen internal/external collaboration success.
 
 
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 Develop and execute a comprehensive territory external (e.g. provider and pharmacy) engagement plan
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 Conduct consistent field visits with external partners to advance operational models' improving pharmacy quality performance
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 Collaborate across stakeholders to ensure critical and timely insights that promote external partner's adoption of new concepts and changes
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 Accountable for covered external partners' pharmacy quality (Part D Patient Safety Measures, HEDIS, PQA, etc.) performance
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 Executive summaries of successes and challenges in external engagement efforts; proactively solutioning or working cross-collaboratively for resolution and associated tracking
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 Ability to travel 40% of time
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 Performs other duties as assigned.
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 Complies with all policies and standards.
 
 
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 </ul>
 
 Education/Experience
 
 
 
 High School Diploma or GED
 
 required
 
 
 
 3+ years of pharmacy experience, preferably in a managed care environment
 
 required
 
 
 
 2+ years experience in business to business (B2B)
 
 required
 
 
 
 1+ years experience with Medicare and/or Medicaid
 
 preferred
 
 
 
 1+ years experience with analysis tools or systems (ex web based, custom, proprietary, etc.)
 
 preferred
 
 
 
 1+ years experience in the implementation of quality process improvement efforts. *Experience documenting requirements, creating training materials and working directly with end users
 
 preferred
 
 
 
 
 Licenses/Certifications
 
 
 
 LPT - Licensed Pharmacy Tech
 
 preferred
 
 
 
 Pay Range $23.23 - $39.61 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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Pharmacy Quality Coordinator

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

Clinical Review Clinician - Appeals

Pharmacy Quality Coordinator