Clinical Appeals Specialist - Remote/Hybrid

Centene Corporation; Lincoln (NE); Hybrid; USD 46,000 - 84,000; Full time

Benefits offered by this job

Remote or hybrid work options

401K and stock purchase plans

Tuition reimbursement

Job summary

Centene Corporation in Lincoln, Nebraska, is seeking a qualified nurse to act as the liaison for statewide appeals, fair hearings, and external appeal processes. You will ensure all appeal letters meet state and NCQA requirements and review clinical information to determine medical necessity.

The role includes preparing reviews, coordinating with Medical Directors, maintaining records, and staying current with NCQA and state regulations.

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 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

Skills

Nursing experience

Utilization review

Case management

Education

RN license

LPN/LVN license

Job description

Centene Corporation in Lincoln, Nebraska, is seeking a qualified nurse to act as the liaison for statewide appeals, fair hearings, and external appeal processes. You will ensure all appeal letters meet state and NCQA requirements and review clinical information to determine medical necessity.

The role includes preparing reviews, coordinating with Medical Directors, maintaining records, and staying current with NCQA and state regulations.