Lead Clinical Appeals Coordinator

Centene Corporation; United States; 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

Job summary

Centene Corporation is seeking an Appeals Liaison to act as the statewide contact for appeals, fair hearings, and external reviews. This remote role requires WA licensure and aligns with NCQA standards, with hours 8:00 am–5:00 pm PST, Monday–Friday.

The role emphasizes reviewing medical necessity, preparing reviews for non-criteria cases, and coordinating with Medical Directors to justify determinations, while maintaining regulatory know-how and reporting on denials and appeals.

Qualifications

• RN with 4+ years of clinical nursing or case management experience, or LPN/LVN with 5+ years of clinical nursing or case management experience.
• Experience with Managed care, Case Management or Utilization Review.

Responsibilities

• Review clinical information for all appeals to determine medical necessity using national criteria.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze and report information on member and provider clinical appeals.
• Prepare compliant response letters for clinical appeals.
• 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 implementation of new processes.
• Prepare monthly/quarterly/annual reports for denials and/or appeals.
• Ensure department coverage and timelines with time-off requests.

Skills

Appeals experience

Lead / team leadership

NCQA/state regulations

Utilization review

Education

RN license (state)

LPN/LVN license

Job description

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

About Centene

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act