Clinical Appeals Coordinator

Centene Management Company LLC; Oregon (WI); Hybrid; USD 47,000 - 84,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work options

Job summary

Centene Corporation is seeking a clinical professional for the Medical Management/Health Services team in Oregon. The role focuses on statewide appeals coordination, ensuring NCQA and state compliance, and reviewing medical necessity of services for diverse member cases.

Responsibilities include preparing reviews, coordinating with Medical Directors, maintaining logs, and reporting outcomes. A Master’s degree in specialty therapy and strong utilization review experience are preferred.

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.
• Managed care or utilization review experience preferred.

Responsibilities

• Act as the liaison for statewide appeals, fair hearings, review organizations, and other external appeals.
• Ensure all appeal letters comply with State and NCQA requirements.
• Review clinical information to determine medical necessity of services requested.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze and report information regarding member and provider clinical appeals.
• Prepare response letters for member and provider clinical appeals and ensure letters comply with standards.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Maintain knowledge of NCQA and State regulations and coordinate Fair Hearings with internal departments.
• Perform other duties as assigned and comply with policies and standards.

Skills

Clinical nursing

Case management

Utilization review

Managed care experience

Education

RN license

LPN/LVN license

Master’s degree in specialty therapy

Job description

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.

RN, LVN/LPN - Licensed in Oregon Pacific Time Work Hours

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 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.

Specialty Therapy Requirement:

• Master’s degree in area of specialty therapy or equivalent experience.
• 3+ years of experience providing therapy services in healthcare or home health settings.
• Managed care or utilization review experience preferred.

Pay Range:

$33.71 - $60.67 per hour

Benefits:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

Equal Opportunity Employer and Diversity Statement:

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.

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.