Remote Lead Clinical Appeals Coordinator - RN/LPN

Centene Corporation; Washington; Hybrid; USD 70.000 - 126.000; Vollzeit

Zusammenfassung

Centene Corporation is seeking a remote appeals liaison with RN or LPN licensure and 4+ years of clinical nursing or case management experience. The role focuses on external appeals, NCQA and state compliance, and coordination with medical directors to ensure timely, accurate responses.

The position requires WA licensure and experience with managed care. Expect collaboration across departments, regular reporting, and adherence to policies and procedures.

Qualifikationen

• 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 is preferred.

Aufgaben

• Review clinical information for appeals to determine medical necessity.
• Prepare reviews for cases that did not meet criteria.
• Gather and report information on member and provider appeals.
• Prepare and ensure NCQA/state compliant appeal letters.
• Coordinate with Medical Directors for clarifications.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments.
• Support training, audits, and policy reviews.
• Prepare denials/appeals reports.
• Manage department workflows and coverage.

Kenntnisse

Appeals review

Leadership

Policy compliance

Ausbildung

RN/LPN licensure

Jobbeschreibung

Centene Corporation is seeking a remote appeals liaison with RN or LPN licensure and 4+ years of clinical nursing or case management experience. The role focuses on external appeals, NCQA and state compliance, and coordination with medical directors to ensure timely, accurate responses.

The position requires WA licensure and experience with managed care. Expect collaboration across departments, regular reporting, and adherence to policies and procedures.