Clinical Appeals Coordinator

Centene Corporation

. Act as liaison for statewide appeals, fair hearings, review organizations, and other external appeals .

Posted 10/12/2026full-timeRemote • Wisconsin • United StatesMid-LevelSenior💰 $34 - $61 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical nursing and case management, with a strong focus on appeals processing and compliance with NCQA and state regulations. Proficient in analyzing clinical information and preparing documentation for appeals in managed care settings.

Highest-signal resume keywords

RN LicenseClinical Nursing ExperienceManaged Care ExperienceUtilization ReviewNCQA Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Information ReviewAppeals ProcessingCase ManagementMedical Necessity DeterminationResponse Letter PreparationData AnalysisFile MaintenanceCoordination with Medical DirectorsFair Hearing CoordinationSpecialty Therapy Experience

Soft Skills

CommunicationCollaborationAnalytical ThinkingAttention to DetailProblem Solving

Certifications & Qualifications

Certificate of Clinical CompetenceState RN LicenseState LPN LicenseState LVN LicenseLPC LicenseLCSW LicensePsy.D License

Industry Keywords

Utilization ManagementManaged CareNCQA StandardsClinical AppealsHealthcare RegulationsHome Health SettingsTherapy ServicesState RegulationsFair HearingsClinical Rationale

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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