Clinical Appeals Coordinator

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🌵 Arizona, Kansas, +3 more states – Remote

🌵 Arizona – Remote 🌪️ Kansas – Remote 🌲 Oregon – Remote 🗿 South Dakota – Remote 🧀 Wisconsin – Remote

💵 $33 - $60 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• 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 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 compliance 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 internal departments and agencies • Perform other duties as assigned • Comply with all policies and standards

🎯 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 • LPN, LVN, or RN license • Specialty Therapy Requirement: 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 • Review clinical information using nationally recognized criteria • Maintain knowledge of NCQA and State regulations

🏖️ Benefits

• Competitive pay • Health insurance • 401K plans • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation