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.
 

***POSITION IS REMOTE BUT MUST RESIDE IN STATE OF OHIO***

Position Purpose: Performs a post-service retrospective review of member medical records and assessing care related to behavioral health to determine if level of care and services were appropriate. Provides observations to senior management for quality-of-care issues and ensures services were administered with quality, cost efficiency and within compliance.

• Performs a post-service retrospective review of member’s medical records provided against guidelines to determine if the services administered were appropriate and with quality at the most efficient and effective level related to behavioral health (BH)
• Reviews medical records related to BH to determine if the codes listed on the submitted bill were correctly coded based on member’s symptoms and in accordance with Current Procedural Terminology (CPT) and other relevant health coding standards (e.g., Healthcare Common Procedure Coding System (HCPCs)
• Reviews medical records for medical necessity of services related to BH to identify quality of care issues and, if identified, refer to the Medical Director or provider for review and verification
• Consults with senior management and BH healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations
• Collects, documents, and maintains data related to quality of care provided to ensure compliance with BH national standards
• Provides education to providers regarding BH retrospective review process
• Provides feedback to leadership on opportunities to improve the retrospective review process for BH members
• Reviews retrospective authorization for extenuating circumstances
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience.



Clinical knowledge and ability to analyze medical records to determine BH care services provided were appropriate preferred.
Knowledge of Medicare, Medicaid, and BH regulations preferred.
Experience performing retrospective reviews of care services related to BH preferred.

License/Certification:

• LCSW- License Clinical Social Worker required or
• LMHC-Licensed Mental Health Counselor required or
• LPC-Licensed Professional Counselor required or
• Licensed Marital and Family Therapist (LMFT) required or
• Licensed Mental Health Professional (LMHP) required or
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Pay Range: $25.97 - $46.68 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.  Total compensation may also include additional forms of incentives.

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