Remote Clinical Appeals Coordinator (RN/LPN)

Centene; Wisconsin; A distancia; USD 46.000 - 84.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Competitive pay

Descripción de la vacante

Centene is seeking a Clinical Appeals Coordinator in a remote-capable role based in Wisconsin. The position focuses on coordinating statewide appeals and ensuring compliance with NCQA and state requirements, with a strong emphasis on case management and operations in a healthcare setting.

You will review clinical information for appeals, prepare reviews for cases not meeting criteria, and gather data on member and provider appeals while coordinating with Medical Directors to clarify

Formación

• Experience with clinical appeals and case management in a managed care setting.
• Familiarity with NCQA standards and state regulations is preferred.
• Licensure as RN, LPN, or LVN is required.

Responsabilidades

• Review clinical information for appeals using recognized criteria.
• Prepare reviews for cases not meeting criteria and coordinate with departments.
• Gather, analyze, and report information on member and provider appeals.
• Prepare response letters ensuring regulatory compliance.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Stay current with NCQA and state regulations; coordinate Fair Hearings as needed.

Conocimientos

Appeals processes

Case management

NCQA standards

Utilization review

Healthcare operations

Educación

RN licensure

LPN/LVN licensure

Descripción del empleo

Centene is seeking a Clinical Appeals Coordinator in a remote-capable role based in Wisconsin. The position focuses on coordinating statewide appeals and ensuring compliance with NCQA and state requirements, with a strong emphasis on case management and operations in a healthcare setting.

You will review clinical information for appeals, prepare reviews for cases not meeting criteria, and gather data on member and provider appeals while coordinating with Medical Directors to clarify