Clinical Appeals Coordinator

Centene Corporation•Remote-NE, NE

5d•$34 - $61

About The Position

The Clinical Appeals Coordinator acts as the liaison for statewide appeals, fair hearings, review organizations, and other external appeals. The role reviews clinical information for appeals using nationally recognized criteria to determine the medical necessity of requested services, and prepares reviews for cases that do not meet criteria. The coordinator gathers, analyzes, and reports verbal and written information regarding member and provider clinical appeals, including follow-up; prepares compliant response letters; maintains appeal files and logs; and works with Medical Directors to clarify medical determinations or clinical rationale. The role also coordinates fair hearings with internal departments and agencies, maintains current knowledge of NCQA and State regulations, and performs other assigned duties while complying with company policies and standards.

Requirements

RN with 4 or more years of clinical nursing and/or case management experience, or LPN/LVN with 5 or more years of clinical nursing or case management experience.
LPN, LVN, or RN license.
For Texas Utilization Management at Superior HealthPlan: RN license required; for the UM Behavioral Health Appeals team: LPC, LCSW, or Psy.D. licensure.
For specialty therapy: current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy. Speech-Language Therapists must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.
For Corporate and Louisiana Healthcare Connections: current state RN, LPN, or LVN, LPC, LCSW, or Psy.D. license.

Nice To Haves

Managed care or utilization review experience.
For specialty therapy: a master's degree in the area of specialty therapy or equivalent experience.
For specialty therapy: 3 or more years of experience providing therapy services in healthcare or home health settings.
Managed care or utilization review experience for specialty therapy roles.

Responsibilities

Act as the liaison for statewide appeals, fair hearings, review organizations, and other external appeals.
Ensure appeal letters comply with State and NCQA requirements.
Review clinical information for appeals using nationally recognized criteria to determine medical necessity of requested services.
Prepare reviews for cases that did not meet criteria.
Gather, analyze, and report verbal and written information regarding member and provider clinical appeals, including follow-up.
Prepare response letters for member and provider clinical appeals and ensure they comply with State and NCQA standards.
Maintain files and logs for all appeals.
Coordinate with Medical Directors 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.