Remote Lead — Clinical Appeals Coordinator

Centene Corporation; Olympia (WA); Remote; USD 47,000 - 84,000; Full time

Job summary

Centene Corporation is seeking a Remote Appeals Liaison to act as the statewide liaison for appeals, fair hearings, and review organizations. WA licensure is required, with 4+ years of nursing or case management and strong NCQA knowledge.

Working hours are Mon-Fri 8:00 am–5:00 pm PST, with an emphasis on accurate medical necessity determinations. Responsibilities include preparing reviews, generating compliant letters, coordinating with Medical Directors, and maintaining NCQA/state regulatory

Qualifications

• RN with 4+ years of clinical nursing or case management experience.
• Experience with Managed care, Case Management or Utilization Review.
• Current state RN, LPN, or LVN license.

Responsibilities

• Review clinical information for appeals utilizing criteria to determine medical necessity.
• 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.
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.
• Maintain current knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments and agencies.
• Facilitate training, auditing and escalations, and assist with policy and procedure reviews and implementation of new processes.
• Prepare monthly, quarterly, and annual reports for denials and/or appeals.
• Coordinate workflows in the department and time off requests to ensure proper coverage.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Appeals liaison

NCQA requirements

Remote work coordination

Leadership experience

Education

RN license (state RN/LPN/LVN)

4+ years nursing/case management

Job description

Centene Corporation is seeking a Remote Appeals Liaison to act as the statewide liaison for appeals, fair hearings, and review organizations. WA licensure is required, with 4+ years of nursing or case management and strong NCQA knowledge.

Working hours are Mon-Fri 8:00 am–5:00 pm PST, with an emphasis on accurate medical necessity determinations. Responsibilities include preparing reviews, generating compliant letters, coordinating with Medical Directors, and maintaining NCQA/state regulatory