Remote RN: Clinical Appeals Coordinator

Delaware First Health; Delaware; A distancia; USD 96.593.000 - 173.845.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off and holidays

Flexible remote work

Descripción de la vacante

Centene is seeking an experienced RN (or LPN/LVN) with 4+ years in clinical nursing or case management to serve as a liaison for statewide appeals and external reviews. You will ensure NCQA and state compliance, prepare appeal letters, and coordinate with Medical Directors from a remote, home-based role.

The position offers standard M-F hours 8:00 a.m. – 5:00 p.m. ET with location-flexible work options and strong focus on regulatory knowledge.

Formación

• RN with 4+ years of clinical nursing and/or case management experience.
• Managed care or utilization review experience preferred.
• Active RN/LPN/LVN license required or strongly preferred.

Responsabilidades

• Act as liaison for statewide appeals, fair hearings, and external appeals.
• Ensure appeal letters comply with State and NCQA requirements.
• Review clinical information to determine medical necessity of services.
• Prepare reviews and response letters for member and provider appeals.
• Maintain files and logs for all appeals and coordinate with Medical Directors.
• Stay current on NCQA and State regulations and coordinate fair hearings.

Conocimientos

RN with 4+ years

Case management experience

Strong communication

Educación

RN license

LPN/LVN license

Descripción del empleo

Centene is seeking an experienced RN (or LPN/LVN) with 4+ years in clinical nursing or case management to serve as a liaison for statewide appeals and external reviews. You will ensure NCQA and state compliance, prepare appeal letters, and coordinate with Medical Directors from a remote, home-based role.

The position offers standard M-F hours 8:00 a.m. – 5:00 p.m. ET with location-flexible work options and strong focus on regulatory knowledge.