Lead Clinical Appeals Coordinator

Centene Corporation•Remote-WA State, WA

7d•$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 is a remote position. Hours are Monday-Friday 8:00 am - 5:00 pm PST. WA State and/or Compact licensure required. Appeals experience and experience as a lead strongly preferred.

Requirements

RN with 4+ years of clinical nursing or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience.
Previous experience with Managed care, Case Management or Utilization Review.
Current state RN, LPN, or LVN license.
WA State and/or Compact licensure required.

Nice To Haves

Appeals experience and experience as a lead strongly 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.
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
Facilitate training, auditing and escalations, and assist with policy and procedure reviews and implementation of new processes
Prepare monthly, quarterly, and annual reports for denials and/or appeals
Coordinate workflows in the department and time off requests to ensure proper coverage
Performs other duties as assigned
Complies with all policies and standards