Clinical Appeals Specialist (RN/LPN) – Remote

Centene Corporation; Wisconsin; Hybrid; USD 46,000 - 84,000; Full time

Benefits offered by this job

Health insurance

401K / Stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible schedules (remote, hybrid, on

Job summary

Centene Corporation in Wisconsin is seeking an Appeals Liaison to coordinate statewide appeals, fair hearings, and external reviews. You will ensure letters meet State and NCQA requirements and work with Medical Directors to clarify medical determinations.

The role requires Wisconsin licensure (RN or LPN/LVN) and experience in managed care or utilization review; prior experience in appeals and case management preferred. Remote, hybrid, or on-site schedules available.

Qualifications

• Must be licensed in Wisconsin (RN/LPN/LVN).
• RN with 4+ years of nursing and/or case management experience.
• LPN/LVN with 5+ years of 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 appeals and ensure NCQA/State compliance.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify determinations.
• Maintain current 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

Utilization management

Appeals management

Case management

Healthcare operations

Education

RN experience

LPN/LVN experience

Master's in specialty therapy

Wisconsin licensure

Job description

Centene Corporation in Wisconsin is seeking an Appeals Liaison to coordinate statewide appeals, fair hearings, and external reviews. You will ensure letters meet State and NCQA requirements and work with Medical Directors to clarify medical determinations.

The role requires Wisconsin licensure (RN or LPN/LVN) and experience in managed care or utilization review; prior experience in appeals and case management preferred. Remote, hybrid, or on-site schedules available.