Remote Clinical Appeals Coordinator (RN)

Centene Corporation; Delaware; Híbrido; USD 47 000 - 84 000; Tempo integral

Resumo da oferta

Centene Corporation is seeking an experienced appeals liaison to work remotely within the Eastern and Central time zones. The role focuses on review of clinical information to determine medical necessity and preparing compliant appeal letters.

Candidates must hold an active RN or LPN/LVN license with several years of clinical or case management experience, with preferred UR/managed care background. Responsibilities include coordinating with Medical Directors, maintaining logs, and ensuring NCQA

Qualificações

• RN license required with 4+ years of clinical nursing and/or case management experience.
• LPN/LVN license required with 5+ years of clinical nursing or case management experience.
• Managed care or utilization review experience preferred.

Responsabilidades

• Act as liaison for statewide appeals, fair hearings, and external appeals to ensure NCQA and state compliance.
• Review clinical information to determine medical necessity of services requested.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze, and report information regarding member and provider clinical appeals.
• Prepare response letters for appeals and ensure compliance with standards.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify determinations.
• Maintain knowledge of NCQA and state regulations.
• Coordinate Fair Hearings with internal departments and agencies.
• Complies with all policies and standards.

Formação académica

RN license

LPN/LVN license

Descrição da oferta de emprego

Centene Corporation is seeking an experienced appeals liaison to work remotely within the Eastern and Central time zones. The role focuses on review of clinical information to determine medical necessity and preparing compliant appeal letters.

Candidates must hold an active RN or LPN/LVN license with several years of clinical or case management experience, with preferred UR/managed care background. Responsibilities include coordinating with Medical Directors, maintaining logs, and ensuring NCQA