Clinical Appeals Coordinator

Centene Corporation•Remote-WI, WI

2d•$34 - $61•Hybrid

About The Position

Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements. 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. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Must be licensed in Wisconsin.
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.
Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy.
Speech-Language Therapist must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.
Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.
3+ years of experience providing therapy services in healthcare or home health settings.
Managed care or utilization review experience preferred.

Nice To Haves

Experience in healthcare, managed care, utilization management, appeals, grievances, case management, or related healthcare operations highly preferred.
Managed care or utilization review experience preferred.
Master’s degree in area of specialty therapy or equivalent experience.

Responsibilities

Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals.
Ensure that all appeal letters generated comply with both State and NCQA requirements.
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.
Performs other duties as assigned.
Complies with all policies and standards.