Remote Lead Clinical Appeals Strategist

Centene Corp.; Washington, United States, Northern America, Americas; Hybrid; USD 47,000 - 83,000; Full time

Job summary

Centene Corp. is seeking a Lead Clinical Appeals Coordinator for a remote position requiring WA licensure.

The role focuses on coordinating statewide clinical appeals, ensuring NCQA and state regulation compliance, and reviewing medical necessity for services requested. Responsibilities include preparing appeal reviews, letters to members and providers, coordinating with Medical Directors, and reporting on denials and appeals.

Qualifications

• RN or LPN/LVN with state licensure and 4+ / 5+ years in nursing or case management.
• Experience with Managed care, Case Management or Utilization Review.
• Knowledge of NCQA standards and state regulations.

Responsibilities

• Review clinical information for appeals to determine medical necessity.
• Prepare reviews for cases not meeting criteria.
• Gather, analyze and report information on member and provider appeals.
• Prepare response letters compliant with State and NCQA standards.
• 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 reviews; implement new processes.
• Prepare monthly, quarterly and annual denial/appeal reports.

Skills

Appeals coordination

Clinical nursing

Case management

Utilization Review

Education

RN license

LPN/LVN license

Job description

Centene Corp. is seeking a Lead Clinical Appeals Coordinator for a remote position requiring WA licensure.

The role focuses on coordinating statewide clinical appeals, ensuring NCQA and state regulation compliance, and reviewing medical necessity for services requested. Responsibilities include preparing appeal reviews, letters to members and providers, coordinating with Medical Directors, and reporting on denials and appeals.