Job Title: Registered Nurse – Intake Location: Remote, US Work Arrangement: Remote Employment Type: Contract Duration: Through March 2027 Domain: Healthcare / Managed Care Pay Rate: $35.00/hr Application Deadline: Oct 29th 2026 SKILLS REQUIRED Primary (Must-Have): Degree from an Accredited School of Nursing or Master’s degree in Behavioral Health or Social Work with 2–4 years of clinical experience. Active, unencumbered RN (State or Compact), LCSW, LMHC, LPC, LMFT, or Licensed Psychologist license. Secondary (Good to Have) In-depth knowledge of NCQA, Medicare, and Medicaid regulatory standards. Demonstrated experience with Utilization Management (UM) processes and clinical documentation review. POSITION OVERVIEW Joining Centene's clinical operations team, this role reports to the Clinical Intake Supervisor and is responsible for evaluating, processing, and resolving complex clinical appeals. By analyzing medical records and clinical data, the incumbent ensures precise medical necessity determinations that support optimal patient outcomes. The position directly mitigates compliance risk and optimizes departmental performance by upholding rigorous regulatory and accreditation standards. ROLES & RESPONSIBILITIES: Performs daily clinical reviews to resolve and process appeals by evaluating medical records and clinical data for medical necessity in accordance with company policies and NCQA standards. Prepares comprehensive case reviews for Medical Directors by researching appeals, evaluating clinical criteria, and analyzing underlying medical bases. Communicates regularly with members, providers, facilities, and internal departments to facilitate timely appeal requests and clarify requirements. Generates official appeal resolution communications and compliance reporting for members and healthcare providers in compliance with State, Federal, and NCQA standards. Partners with leadership and interdepartmental teams to refine clinical appeal workflows, drive process efficiency, and implement industry best practices. BENEFITS Medical | Dental | Vision | 401(k) EEOC Compliance We are an equal opportunity employer, and all qualified applicants will receive consideration for employment. DISCLAIMER AI Usage Policy: Pacer Group uses AI to assist in screening applications. Final hiring decisions are made by human recruiters based on qualifications and experience.