Remote Clinical Appeals Coordinator (Utilization Review)

Centene Corporation; City of Syracuse (NY); Hybrid; 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 (remote,Hybrid

Job summary

Centene Corporation is seeking a qualified RN/LPN-based professional to act as a liaison for statewide appeals, reviews patient clinical data, and prepare compliant response letters in line with State and NCQA standards. Experience in managed care or utilization review is preferred.

The role requires 4+ years of clinical nursing or case management with an RN or 5+ years with an LPN/LVN, plus an active license. A Master’s in therapy adds value.

Qualifications

• RN with 4+ years of clinical nursing and/or case management experience.
• LPN/LVN with 5+ years of clinical nursing or case management experience. Managed care or utilization review experience preferred.
• LPN, LVN, or RN license.
• Master’s degree in area of specialty therapy or equivalent experience. 3+ years of experience providing therapy services in healthcare or home health settings.

Responsibilities

• Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external appeals.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze and report information regarding member and provider clinical appeals.
• Prepare response letters for member and provider clinical appeals and ensure letters comply with State and NCQA standards.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments and agencies.

Education

RN with 4+ years of clinical nursing and/or case management experience

LPN/LVN with 5+ years of clinical nursing or case management experience

LPN, LVN, or RN license

Master’s degree in area of specialty therapy or equivalent experience

Job description

Centene Corporation is seeking a qualified RN/LPN-based professional to act as a liaison for statewide appeals, reviews patient clinical data, and prepare compliant response letters in line with State and NCQA standards. Experience in managed care or utilization review is preferred.

The role requires 4+ years of clinical nursing or case management with an RN or 5+ years with an LPN/LVN, plus an active license. A Master’s in therapy adds value.