Clinical Appeals Coordinator

Job not on LinkedIn

🔥 14 hours ago

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

💵 $33 - $60 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 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 • 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 • Maintain files and logs for all appeals • Coordinate with Medical Directors to clarify medical determinations or clinical rationale • Coordinate Fair Hearings with internal departments and agencies • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• Must be licensed in Wisconsin • 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 highly preferred • LPN, LVN, or RN license • RN license required within Utilization Management at Superior HealthPlan or LPC, LCSW or Psy D. licensure within UM Behavioral Health Appeals team for Texas requirements • Specialty therapy: Master’s degree in area of specialty therapy or equivalent experience • Specialty therapy: 3+ years of experience providing therapy services in healthcare or home health settings • Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy • Speech-Language Therapist must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association • Corporate & Louisiana Healthcare Connections: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license • Maintain knowledge of NCQA and State regulations

🏖️ Benefits

• Health insurance • 401K • 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