Remote Lead Clinical Appeals Specialist

Centene Corporation; United States; Remote; USD 46,000 - 84,000; Full time

Benefits offered by this job

Health Insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Job summary

Centene Corporation is seeking an Appeals Liaison to act as the statewide contact for appeals, fair hearings, and external reviews. This remote role requires WA licensure and aligns with NCQA standards, with hours 8:00 am–5:00 pm PST, Monday–Friday.

The role emphasizes reviewing medical necessity, preparing reviews for non-criteria cases, and coordinating with Medical Directors to justify determinations, while maintaining regulatory know-how and reporting on denials and appeals.

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.
• 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 for cases that did not meet criteria.
• Gather, analyze and report information on member and provider clinical appeals.
• Prepare compliant response letters for clinical appeals.
• Coordinate with Medical Directors to clarify medical determinations.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments and agencies.
• Facilitate training, auditing and policy implementation of new processes.
• Prepare monthly/quarterly/annual reports for denials and/or appeals.
• Ensure department coverage and timelines with time-off requests.

Skills

Appeals experience

Lead / team leadership

NCQA/state regulations

Utilization review

Education

RN license (state)

LPN/LVN license

Job description

Centene Corporation is seeking an Appeals Liaison to act as the statewide contact for appeals, fair hearings, and external reviews. This remote role requires WA licensure and aligns with NCQA standards, with hours 8:00 am–5:00 pm PST, Monday–Friday.

The role emphasizes reviewing medical necessity, preparing reviews for non-criteria cases, and coordinating with Medical Directors to justify determinations, while maintaining regulatory know-how and reporting on denials and appeals.