Clinical Appeals Coordinator

Centene Corporation; United States; Remote; USD 46,000 - 84,000; Full time

Benefits offered by this job

Health insurance

401K

Tuition reimbursement

Job summary

Centene Corporation is seeking an RN- or LPN/LVN-licensed nurse to serve as a liaison for statewide appeals, fair hearings, and external reviews. This remote role supports Eastern and Central time zones with a standard 8–5 schedule and requires an active U.S. license.

You will prepare review letters that comply with State and NCQA standards and maintain detailed appeal files. Ideal candidates have 4+ years of clinical nursing or case management, and experience in managed care or utilization

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

• Review clinical information for appeals to determine medical necessity.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze and report information regarding member and provider appeals.
• Prepare response letters for member and provider clinical appeals and ensure NCQA compliance.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify medical determinations.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments and agencies.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical nursing

Case management

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.

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