Remote RN: Clinical Appeals Specialist

Centene Corporation; New York (NY); Remote; USD 70,000 - 126,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Total compensation incentives

Program eligibility

Job summary

Centene is seeking an RN with strong appeal review experience to act as liaison for statewide appeals, fair hearings, and review organizations. This fully remote role supports members and providers while ensuring compliance with State and NCQA standards.

Candidates must hold an active RN license and have 4+ years of clinical nursing or case management experience; LPN/LVN with 5+ years is acceptable. Pay ranges from $33.71 to $60.67 per hour, with benefits and flexible schedules.

Qualifications

• RN with 4+ years of clinical nursing and/or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience.
• Managed care or utilization review experience preferred.

Responsibilities

• 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.
• Maintain files and logs for all appeals.
• 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.
• Perform other duties as assigned.
• Comply with all policies and standards.

Skills

Clinical nursing

Case management

Utilization review

NCQA standards knowledge

Education

RN with 4+ years experience

LPN/LVN with 5+ years experience

Job description

Centene is seeking an RN with strong appeal review experience to act as liaison for statewide appeals, fair hearings, and review organizations. This fully remote role supports members and providers while ensuring compliance with State and NCQA standards.

Candidates must hold an active RN license and have 4+ years of clinical nursing or case management experience; LPN/LVN with 5+ years is acceptable. Pay ranges from $33.71 to $60.67 per hour, with benefits and flexible schedules.