Clinical Appeals Coordinator

Centene Corporation • Remote-OR, OR

4d • $34 - $61 • Remote

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. This position will work Pacific Time Zone hours. At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Requirements

• Must have an unencumbered RN, LVN or LPN license in the state of Oregon.
• 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.
• LPN, LVN, or RN license.
• 3+ years of experience providing therapy services in healthcare or home health settings.

Nice To Haves

• Managed care or utilization review experience preferred.
• 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
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• competitive pay
• health insurance
• 401K
• stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level