Clinical Appeals Coordinator

Centene Management Company LLC; Wisconsin; Hybrid; USD 46,000 - 84,000; Full time

Job summary

Centene Management Company LLC in Wisconsin seeks a licensed RN or LPN/LVN to act as liaison for statewide appeals, fair hearings, and external reviews. The role ensures that medical necessity determinations meet State and NCQA standards and requires coordination with Medical Directors for clarification of clinical rationale.

The position emphasizes maintaining thorough records, ensuring compliance, and collaborating with multiple departments to support members and providers throughout the

Qualifications

• 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.
• Licensed in Wisconsin as RN/LPN/LVN is required.

Responsibilities

• Act as liaison for statewide appeals, fair hearings, and external type appeals.
• Review clinical information to determine medical necessity of services requested.
• Prepare reviews and letters compliant with State and NCQA standards.
• Coordinate with Medical Directors to clarify medical determinations.
• Maintain files and logs for all appeals and coordinate with internal departments.

Skills

Healthcare operations

Appeals processing

NCQA standards

Regulatory compliance

Education

RN with 4+ years

LPN/LVN with 5+ years

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

Must be licensed in Wisconsin. Experience in healthcare, managed care, utilization management, appeals, grievances, case management, or related healthcare operations highly preferred. 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.

Texas Requirements

RN license required within Utilization Management at Superior HealthPlan or LPC, LCSW or Psy D. licensure within UM Behavioral Health Appeals team.

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.

Licenses/Certifications

Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy. Speech-Language Therapist must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Corporate & Louisiana Healthcare Connections Requirements

Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.

Pay Range

$33.71 - $60.67 per hour

About Centene

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.

Equal Opportunity 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

Company Commitment

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.