Clinical Appeals Coordinator

Centene Corporation; Oregon (WI); Hybrid; USD 46,000 - 84,000; Full time

Job summary

Centene Corporation seeks a clinical professional on the Medical Management/Health Services team in Oregon for our RN/LVN roles. You will oversee statewide appeals, ensuring adherence to NCQA and state standards while coordinating with medical leadership and external bodies.

Qualifications include RN with 4+ years or LPN/LVN with 5+ years in clinical nursing or case management; a Master’s in specialty therapy is 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.
• LPN, LVN, or RN license.

Responsibilities

• Act as the liaison for statewide appeals, fair hearings, review organizations and external type appeals.
• Review clinical information to determine medical necessity of services requested.
• Prepare reviews and letters for member and provider clinical appeals in compliance with State and NCQA requirements.
• Maintain files/logs for all appeals and coordinate with Medical Director(s) as needed.
• Stay current with NCQA and State regulations and coordinate Fair Hearings with internal departments.

Skills

Clinical nursing

Case management

Utilization review

Education

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

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