Clinical Appeals Coordinator

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

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Competitive pay

Job summary

Centene is seeking a Clinical Appeals Coordinator in a remote-capable role based in Wisconsin. The position focuses on coordinating statewide appeals and ensuring compliance with NCQA and state requirements, with a strong emphasis on case management and operations in a healthcare setting.

You will review clinical information for appeals, prepare reviews for cases not meeting criteria, and gather data on member and provider appeals while coordinating with Medical Directors to clarify

Qualifications

• Experience with clinical appeals and case management in a managed care setting.
• Familiarity with NCQA standards and state regulations is preferred.
• Licensure as RN, LPN, or LVN is required.

Responsibilities

• Review clinical information for appeals using recognized criteria.
• Prepare reviews for cases not meeting criteria and coordinate with departments.
• Gather, analyze, and report information on member and provider appeals.
• Prepare response letters ensuring regulatory compliance.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Stay current with NCQA and state regulations; coordinate Fair Hearings as needed.

Skills

Appeals processes

Case management

NCQA standards

Utilization review

Healthcare operations

Education

RN licensure

LPN/LVN licensure

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 experience in healthcare operations, particularly in appeals and case management.

Highlights

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

What You'll Do

• Review clinical information for all appeals utilizing nationally recognized criteria.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze, and report information regarding member and provider clinical appeals.
• Prepare response letters for clinical 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.
• Perform other duties as assigned.
• 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 RN, LPN, or LVN required.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules

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, making a real impact every day through meaningful challenges and a commitment to improving lives.