Remote/Hybrid Clinical Appeals Coordinator

Centene Management Company LLC; Wisconsin; Hybrid; USD 46,000 - 84,000; Full time

Job summary

Centene Management Company LLC in Wisconsin seeks a licensed RN or LPN/LVN to act as liaison for statewide appeals, fair hearings, and external reviews. The role ensures that medical necessity determinations meet State and NCQA standards and requires coordination with Medical Directors for clarification of clinical rationale.

The position emphasizes maintaining thorough records, ensuring compliance, and collaborating with multiple departments to support members and providers throughout the

Qualifications

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

Responsibilities

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

Skills

Healthcare operations

Appeals processing

NCQA standards

Regulatory compliance

Education

RN with 4+ years

LPN/LVN with 5+ years

Job description

Centene Management Company LLC in Wisconsin seeks a licensed RN or LPN/LVN to act as liaison for statewide appeals, fair hearings, and external reviews. The role ensures that medical necessity determinations meet State and NCQA standards and requires coordination with Medical Directors for clarification of clinical rationale.

The position emphasizes maintaining thorough records, ensuring compliance, and collaborating with multiple departments to support members and providers throughout the