Clinical Appeals & Compliance Lead

Centene Corp.; Northern (KY); Hybrid; USD 70,000 - 126,000; Full time

Job summary

Centene Corp. is seeking a qualified nurse to serve as statewide appeals liaison, coordinating with medical directors to clarify determinations and ensuring NCQA-compliant communications.

The role requires strong experience in utilization management, appeals, and case management, with active RN/LPN/LVN licensure and knowledge of state regulations. Prior exposure to Fair Hearings processes is a plus.

Qualifications

• RN with 4+ years of clinical nursing and/or case management experience.
• LPN/LVN with 5+ years of clinical nursing or case management experience.
• License: LPN, LVN, or RN.
• Texas UM requires RN license within Utilization Management.
• Master’s degree in area of specialty therapy or equivalent experience.
• 3+ years of experience providing therapy services in healthcare or home health settings.
• Current state licenses in Physical Therapy, Occupational Therapy or Speech-Language Therapy; CCC-SLP.

Responsibilities

• Review clinical information for appeals to determine medical necessity.
• Prepare reviews for cases not meeting criteria.
• Gather, analyze, and report information on member and provider appeals.
• Prepare response letters compliant with State and NCQA standards.
• Maintain files and logs for all appeals; coordinate with Medical Director(s).
• Stay current on NCQA and State regulations; coordinate Fair Hearings with internal departments.

Skills

Healthcare experience

Managed care

Utilization management

Appeals

Grievances

Case management

Education

RN license

LPN/LVN license

Master's degree in specialty therapy

CCC-SLP (Certificate of Clinical Competence)

Job description

Centene Corp. is seeking a qualified nurse to serve as statewide appeals liaison, coordinating with medical directors to clarify determinations and ensuring NCQA-compliant communications.

The role requires strong experience in utilization management, appeals, and case management, with active RN/LPN/LVN licensure and knowledge of state regulations. Prior exposure to Fair Hearings processes is a plus.