Clinical Appeals Coordinator

Delaware First Health; Delaware; Remote; USD 96,593,000 - 173,845,000; Full time

Benefits offered by this job

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off and holidays

Flexible remote work

Job summary

Centene is seeking an experienced RN (or LPN/LVN) with 4+ years in clinical nursing or case management to serve as a liaison for statewide appeals and external reviews. You will ensure NCQA and state compliance, prepare appeal letters, and coordinate with Medical Directors from a remote, home-based role.

The position offers standard M-F hours 8:00 a.m. – 5:00 p.m. ET with location-flexible work options and strong focus on regulatory knowledge.

Qualifications

• RN with 4+ years of clinical nursing and/or case management experience.
• Managed care or utilization review experience preferred.
• Active RN/LPN/LVN license required or strongly preferred.

Responsibilities

• Act as liaison for statewide appeals, fair hearings, and external appeals.
• Ensure appeal letters comply with State and NCQA requirements.
• Review clinical information to determine medical necessity of services.
• Prepare reviews and response letters for member and provider appeals.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Stay current on NCQA and State regulations and coordinate fair hearings.

Skills

RN with 4+ years

Case management experience

Strong communication

Education

RN license

LPN/LVN license

Job description

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.

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.

Key Details: This is a fully remote, work-from-home position open to candidates in the Eastern and Central time zones. The standard schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. ET, with some flexibility based on location. Candidates must hold an active RN license in any U.S. state; a compact license is preferred but not required.

• 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 criteria
• Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up
• Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.
• Maintain files and logs for all appeals
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale
• Maintain current knowledge of NCQA and State regulations
• Coordinate Fair Hearings with various internal departments and agencies
• Performs other duties as assigned
• Complies with all policies and standards
  
  

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 (strongly preferred).

Pay Range: $33.71 - $60.67 per hour

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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