Remote Lead Clinical Appeals Coordinator

Centene Corporation; Seattle (WA); Remote; USD 46,000 - 84,000; Full time

Job summary

Centene Corporation seeks a registered nurse or licensed practical nurse with 4+ years of clinical nursing or case management experience to act as the statewide appeals liaison. The role ensures medical necessity reviews meet NCQA and state requirements and coordinates with medical directors.

Work is remote with standard hours; WA licensure is required. The ideal candidate has Managed care or Utilization Review exposure and can lead appeal processes across the state.

Qualifications

• RN with 4+ years of clinical nursing or LPN/LVN with 5+ years of clinical nursing or case management experience.
• Experience with Managed care, Case Management, or Utilization Review.

Responsibilities

• Review clinical information for all appeals to determine medical necessity using national criteria.
• Prepare reviews and letters for members and providers compliant with NCQA standards.
• Coordinate with Medical Directors to clarify medical determinations and rationale.
• Prepare monthly, quarterly, and annual reports for denials and appeals.
• Maintain up-to-date knowledge of NCQA and state regulations.

Skills

Appeals coordination

Healthcare regulations

Education

RN with 4+ years or LPN/LVN with 5+ years clinical nursing

Job description

Centene Corporation seeks a registered nurse or licensed practical nurse with 4+ years of clinical nursing or case management experience to act as the statewide appeals liaison. The role ensures medical necessity reviews meet NCQA and state requirements and coordinates with medical directors.

Work is remote with standard hours; WA licensure is required. The ideal candidate has Managed care or Utilization Review exposure and can lead appeal processes across the state.