Clinical Appeals Coordinator
📋 Role Overview & Responsibilities
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 Purpose Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements.
Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not meet criteriaGather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow upPrepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.Maintain files and logs for all appealsCoordinate with Medical Director(s) to clarify medical determinations or clinical rationaleMaintain current knowledge of NCQA and State regulationsCoordinate Fair Hearings with various internal departments and agencies
Education/Experience RN with 4+ years of clinical nursing and/or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Managed care or utilization review experience preferred.
License/Certification LPN, LVN, or RN license.
Location Position is 100% remote.
Pay Range $32.41 - $58.31 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.
Frequently Asked Questions
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This position is located in Arkansas, United States with potential relocation and sponsorship assistance depending on candidate qualifications.
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