Remote Clinical Excellence Nurse, OK


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Business Area: Clinical & Care Management
Job Type: Full time
Job Number: 1474980


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 live in Oklahoma

Oklahoma 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 guidelines.
  • 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 clinical documentation.
  • Provides feedback and recommendations on how to improve areas of deficiency related to policies, procedures, and documentation standards.
  • Recognizes opportunities to improve the quality of care/services and activities to continually strive to improve outcomes.
  • 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 outcomes.
  • 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 communication skills.

License/Certifications: Licensed Practical Nruse (LPN) is 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, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.