Remote Clinical Appeals & Compliance Liaison

Centene Corporation; Kansas; Hybrid; USD 70,000 - 125,000; 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 arrangement

Job summary

Centene Corporation is seeking a Nurse Appeals Reviewer to act as liaison for statewide appeals, fair hearings, and external appeals, ensuring NCQA and state compliance. You will review clinical information to determine medical necessity, prepare reviews, gather and report information, and maintain logs.

Remote/hybrid/office options available, with competitive pay and comprehensive benefits. You will collaborate with Medical Directors and stay current on NCQA/state regulations, handling complex

Qualifications

• RN with 4+ years of clinical nursing or LPN/LVN with 5+ years of clinical 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 not meeting criteria.
• Gather, analyze and report information regarding member and provider appeals.
• Prepare response letters compliant with State and NCQA standards.
• Maintain files/logs for all appeals.
• Coordinate with Medical Directors for determinations.

Skills

Clinical nursing

Case management

Utilization review

Education

RN licensure

LPN/LVN licensure

Job description

Centene Corporation is seeking a Nurse Appeals Reviewer to act as liaison for statewide appeals, fair hearings, and external appeals, ensuring NCQA and state compliance. You will review clinical information to determine medical necessity, prepare reviews, gather and report information, and maintain logs.

Remote/hybrid/office options available, with competitive pay and comprehensive benefits. You will collaborate with Medical Directors and stay current on NCQA/state regulations, handling complex