Remote Clinical Appeals Specialist

Centene Management Company LLC; Kansas; 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

Job summary

Centene is seeking a skilled nurse with extensive experience in appeals, utilization review, and case management to coordinate statewide processes. The role emphasizes compliance with State and NCQA standards and close collaboration with Medical Directors to ensure accurate medical determinations.

The position supports a flexible work approach, offering remote, hybrid, field, or office scheduling options. Candidates should have significant nursing experience and a background in managed care.

Qualifications

• RN/LPN/LVN nursing degree required or equivalent licensure.
• 4+ years of clinical nursing and/or case management experience.
• Managed care or utilization review experience preferred.

Responsibilities

• Act as liaison for statewide appeals, fair hearings, and external appeals.
• Review clinical information to determine medical necessity of services requested.
• Prepare reviews and follow up letters compliant with State and NCQA standards.
• Coordinate with Medical Directors to clarify medical determinations.
• Maintain files and logs for all appeals and coordinate fair hearings.

Skills

Clinical nursing

Case management

Utilization review

Education

Nursing degree

Job description

Centene is seeking a skilled nurse with extensive experience in appeals, utilization review, and case management to coordinate statewide processes. The role emphasizes compliance with State and NCQA standards and close collaboration with Medical Directors to ensure accurate medical determinations.

The position supports a flexible work approach, offering remote, hybrid, field, or office scheduling options. Candidates should have significant nursing experience and a background in managed care.