Clinical Appeals Coordinator — Remote & Hybrid Impact

Centene Corporation; Nebraska; Hybrid; 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 arrangements (remote/hyb

Job summary

Centene Corporation seeks an experienced appeals reviewer to evaluate clinical information for all appeals using nationally recognized criteria to determine medical necessity of services requested. You will prepare reviews for cases that did not meet criteria and coordinate with Medical Directors for clarity.

The role requires RN/LPN/LVN licensure with 4+ years of clinical nursing or case management experience; Master’s in therapy and utilization review experience are highly regarded.

Qualifications

• RN with 4+ years of clinical nursing and/or case management experience.
• Managed care or utilization review experience preferred.
• Licensure as RN, LPN or LVN required; therapy credentialing preferred.

Responsibilities

• Review clinical information for appeals using recognized criteria to determine medical necessity.
• Prepare reviews for cases that did not meet criteria and gather/report information.
• Prepare response letters for appeals compliant with NCQA and state standards.
• Coordinate with Medical Directors and other departments on determinations.

Skills

Clinical nursing

Case management

Utilization review

Education

RN license

LPN/LVN license

Master’s degree in therapy

Job description

Centene Corporation seeks an experienced appeals reviewer to evaluate clinical information for all appeals using nationally recognized criteria to determine medical necessity of services requested. You will prepare reviews for cases that did not meet criteria and coordinate with Medical Directors for clarity.

The role requires RN/LPN/LVN licensure with 4+ years of clinical nursing or case management experience; Master’s in therapy and utilization review experience are highly regarded.