Remote Lead Clinical Appeals Coordinator (RN/LPN)

Centene Management Company LLC; Washington; Hybride; USD 47 000 - 84 000; Plein temps

Avantages offerts par ce poste

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Résumé du poste

Centene Management Company LLC is seeking an experienced appeals liaison to manage statewide and external clinical appeals in a remote role. The position requires WA state or compact licensure, with hours Monday through Friday 8:00 am to 5:00 pm PST, and familiarity with NCQA standards.

You will review clinical information, prepare response letters, coordinate with Medical Directors, and produce regular denials/appeals reports while ensuring compliance and timely workflows in a healthcare

Qualifications

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

Responsabilités

• Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested.
• Prepare reviews for cases that did not meet criteria.
• Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up.
• Prepare response letters for member and provider clinical appeals and ensure letters are compliant 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 various 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.

Connaissances

Appeals experience

Lead experience

NCQA knowledge

Formation

RN license

Description du poste

Centene Management Company LLC is seeking an experienced appeals liaison to manage statewide and external clinical appeals in a remote role. The position requires WA state or compact licensure, with hours Monday through Friday 8:00 am to 5:00 pm PST, and familiarity with NCQA standards.

You will review clinical information, prepare response letters, coordinate with Medical Directors, and produce regular denials/appeals reports while ensuring compliance and timely workflows in a healthcare