Remote Clinical Appeals Specialist

Centene Management Company LLC; Oregon (WI); Hybrid; USD 47,000 - 84,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work options

Job summary

Centene Corporation is seeking a clinical professional for the Medical Management/Health Services team in Oregon. The role focuses on statewide appeals coordination, ensuring NCQA and state compliance, and reviewing medical necessity of services for diverse member cases.

Responsibilities include preparing reviews, coordinating with Medical Directors, maintaining logs, and reporting outcomes. A Master’s degree in specialty therapy and strong utilization review experience are preferred.

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.

Responsibilities

• Act as the liaison for statewide appeals, fair hearings, review organizations, and other external appeals.
• Ensure all appeal letters comply with State and NCQA requirements.
• 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 member and provider clinical appeals and ensure letters comply with standards.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Maintain knowledge of NCQA and State regulations and coordinate Fair Hearings with internal departments.
• Perform other duties as assigned and comply with policies and standards.

Skills

Clinical nursing

Case management

Utilization review

Managed care experience

Education

RN license

LPN/LVN license

Master’s degree in specialty therapy

Job description

Centene Corporation is seeking a clinical professional for the Medical Management/Health Services team in Oregon. The role focuses on statewide appeals coordination, ensuring NCQA and state compliance, and reviewing medical necessity of services for diverse member cases.

Responsibilities include preparing reviews, coordinating with Medical Directors, maintaining logs, and reporting outcomes. A Master’s degree in specialty therapy and strong utilization review experience are preferred.