Clinical Appeals Coordinator

Centene; Nebraska; Remote; USD 46,000 - 84,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules (remote,hybrid

Flexible work schedules (remote, field

Job summary

Centene is seeking a Clinical Appeals Coordinator to act as the statewide liaison for appeals, ensuring NCQA and state compliance. Ideal for clinicians with case management experience who are detail-oriented and skilled in communication.

This remote role in Nebraska supports a full-time day schedule, collaborating with Medical Directors and internal teams to maintain compliance and drive timely outcomes. The position emphasizes review of medical necessity, preparation of appeal responses, and

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.
• Current state license as LPN, LVN, or RN.

Responsibilities

• Act as the liaison for all statewide appeals and fair hearings.
• Review clinical information for all appeals to determine medical necessity.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze, and report information regarding member and provider clinical appeals.
• Prepare response letters for appeals ensuring compliance with standards.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify medical determinations.
• Maintain current knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with various internal departments and agencies.
• Comply with all policies and standards.

Skills

Clinical nursing

Case management

Communication

Detail-oriented

Education

RN with 4+ years of clinical nursing or case management

LPN/LVN with 5+ years of clinical nursing or case management

Job description

About This Role

The Clinical Appeals Coordinator acts as the liaison for statewide appeals, ensuring compliance with State and NCQA requirements. This role is ideal for individuals with strong clinical and case management experience who are detail-oriented and skilled in communication.

Highlights

• Pay: $33.71 - $60.67/hour
• Location: Remote, NE
• Schedule: Full Time, Day shift

What You'll Do

• Act as the liaison for all statewide appeals and fair hearings.
• Review clinical information for all appeals to determine medical necessity.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze, and report information regarding member and provider clinical appeals.
• Prepare response letters for appeals ensuring compliance with standards.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify medical determinations.
• Maintain current knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with various internal departments and agencies.
• Comply with all policies and standards.

Requirements

Education

• 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.

Experience

• Managed care or utilization review experience preferred.

Licenses & Certifications

• Current state license as LPN, LVN, or RN.
• RN license required within Utilization Management at Superior HealthPlan or LPC, LCSW, or Psy D. licensure within UM Behavioral Health Appeals team.
• Current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules (remote, hybrid, field, or office)

About Centene

Centene is a leading healthcare provider committed to delivering exceptional patient care. They connect people to the care they need to live healthier lives, supporting individuals, families, and communities through meaningful challenges and a comprehensive benefits package.