Lead Clinical Appeals Coordinator

Centene Corp.; Northern (KY); Hybrid; USD 47,000 - 83,000; Full time

Job summary

Centene Corp. is seeking a Lead Clinical Appeals Coordinator for a remote position requiring WA licensure.

The role focuses on coordinating statewide clinical appeals, ensuring NCQA and state regulation compliance, and reviewing medical necessity for services requested. Responsibilities include preparing appeal reviews, letters to members and providers, coordinating with Medical Directors, and reporting on denials and appeals.

Qualifications

• RN or LPN/LVN with state licensure and 4+ / 5+ years in nursing or case management.
• Experience with Managed care, Case Management or Utilization Review.
• Knowledge of NCQA standards and state regulations.

Responsibilities

• Review clinical information for appeals to determine medical necessity.
• Prepare reviews for cases not meeting criteria.
• Gather, analyze and report information on member and provider appeals.
• Prepare response letters compliant with State and NCQA standards.
• Coordinate with Medical Directors to clarify medical determinations.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments and agencies.
• Facilitate training, auditing and policy reviews; implement new processes.
• Prepare monthly, quarterly and annual denial/appeal reports.

Skills

Appeals coordination

Clinical nursing

Case management

Utilization Review

Education

RN license

LPN/LVN license

Job description

## Lead Clinical Appeals CoordinatorApply: Remote-WA State: Full time: Posted Today: 1665328**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:** This is a remote position. Hours are Monday-Friday 8:00 am - 5:00 pm PST. WA State and/or Compact licensure required. Appeals experience and experience as a lead strongly 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.* 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* Facilitate training, auditing and escalations, and assist with policy and procedure reviews and implementation of new processes* Prepare monthly, quarterly, and annual reports for denials and/or appeals* Coordinate workflows in the department and time off requests to ensure proper coverage* Performs other duties as assigned* Complies with all policies and standards**Education/Experience:** RN with 4+ years of clinical nursing or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Previous experience with Managed care, Case Management or Utilization Review. **License/Certification:** Current state RN, LPN, or LVN license.Pay Range: $33.71 - $60.67 per hour