Clinical Excellence Nurse
Posted on: November 20, 2023
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
Must live in OklahomaOklahoma Complete Health, a Centene company,
is committed to providing quality healthcare solutions to transform
the health of Oklahomans.
At Oklahoma Complete Health, we are community advocates and
change-makers in search of an inclusive culture grounded by our
commitment to work-life balance, competitive compensation, and
continuous career development. Join us and be a part of a
collaborative, growing network of innovative thinkers delivering
solutions at the local level.Position Purpose: This position
reviews and audits all adverse decisions for members of the health
plan while utilizing clinical expertise and specific tools for best
practice and compliance. Clinical audits focus on medical and
behavioral health utilization denials. Maintains Federal and Local
guidelines to meet general accreditation status with regard to
denial letters. Writes all denial letters.
- Reviews all aspects of the denials processes to promote
consistency and accuracy within the processes and compliance with
Medicare, NCQA, URAC or general accreditation, regulatory and HIPAA
- Maintains a current knowledge of medical and UM policies
utilized in the review process.
- Maintain current knowledge of review policies, procedures,
documentation standards and identify areas of improvement in
- Provides feedback and recommendations on how to improve areas
of deficiency related to policies, procedures, and documentation
- Recognizes opportunities to improve the quality of
care/services and activities to continually strive to improve
- Provides expertise or general support to Denials Specialist
staff in reviewing, researching, investigating, negotiating and
resolving all types of denials.
- Maintain production and quality standards.
- Recommend areas for remediation opportunities based on audit
- Meets all relevant regulatory requirements and comprehends and
complies with best practices, professional standards, internal
policies and procedures.
- Perform other duties as assigned.Education/Experience: A High
School or GED is required. A Bachelor's Degree in nursing,
healthcare or related field is preferred. 2+ years of experience in
chart audit, utilization review, case management, clinical claims
reviews or relevant position directly related to the position is
required. 1+ year of experience in medical and behavioral review is
preferred. Ability to provide clearly written feedback that will be
used as part of an overall clinical staff remediation process.
Knowledge of NCQA, URAC or general accreditation requirements and
guidelines for utilization management and denials. knowledge of
healthcare delivery. Ability to work independently, multi-task,
effectively present information and respond to questions from
families, members and providers as well as effectively present
information and respond to question from peers and management.
Ability to create, review and interpret treatment plans.
Demonstrated time management, priority setting skills, problem
solving skills as well as interpersonal, verbal, and written
License/Certifications: Licensed Practical Nruse (LPN) is
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, sex, sexual orientation,
gender identity, national origin, disability, veteran status, or
other characteristic protected by applicable law.
Keywords: Centene, Midwest City , Clinical Excellence Nurse, Other , Shawnee, Oklahoma
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