Lead Clinical Appeals Coordinator

🔥 1 minute ago

☕ Washington – Remote

☕ Washington – Remote

💵 $33 - $60 / hour

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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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 • Prepare compliant response letters for member and provider clinical appeals • Coordinate with Medical Directors to clarify medical determinations or clinical rationale • Maintain current knowledge of NCQA and State regulations • Coordinate Fair Hearings with internal departments and agencies • Facilitate training, auditing, and escalations • Assist with policy and procedure reviews and implementation of new processes • Prepare monthly, quarterly, and annual reports for denials and/or appeals • Coordinate department workflows and time-off requests to ensure proper coverage • Perform other duties as assigned • Comply with all policies and standards

🎯 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 • Appeals experience and experience as a lead strongly preferred • Ability to work Monday-Friday, 8:00 am–5:00 pm PST • Knowledge of NCQA and State regulations • Ability to review clinical information and determine medical necessity using nationally recognized criteria

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • 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 • Equal opportunity employer committed to diversity