Clinical Appeals Coordinator

Centene Corporation•Remote-OR, NV

1d•$34 - $61•Remote

About The Position

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Requirements

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.
LPN, LVN, or RN license.
Master’s degree in area of specialty therapy or equivalent experience.
3+ years of experience providing therapy services in healthcare or home health settings.
Managed care or utilization review experience preferred.

Nice To Haves

Managed care or utilization review experience preferred.

Responsibilities

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