Lead Clinical Appeals Coordinator

Centene Management Company LLC; Washington; Hybrid; USD 47,000 - 84,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Job summary

Centene Management Company LLC is seeking an experienced appeals liaison to manage statewide and external clinical appeals in a remote role. The position requires WA state or compact licensure, with hours Monday through Friday 8:00 am to 5:00 pm PST, and familiarity with NCQA standards.

You will review clinical information, prepare response letters, coordinate with Medical Directors, and produce regular denials/appeals reports while ensuring compliance and timely workflows in a healthcare

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.
• Previous experience with Managed care, Case Management or Utilization Review.

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.
• 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.

Skills

Appeals experience

Lead experience

NCQA knowledge

Education

RN 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.

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.
• 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.

Benefits

• 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.

Equal Opportunity

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.

Accommodation

Should you need an accommodation, please email [e-mail].

Mission Statement

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.