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Clinical Appeals Coordinator
Centene Corporation. Act as liaison for statewide appeals, fair hearings, review organizations, and other external appeals .
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 do not meet criteria
- Gather, analyze, and report 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
- Maintain current knowledge of NCQA and State regulations
- Coordinate Fair Hearings with internal departments and agencies
- Perform other assigned duties and comply with policies and standards
Requirements
What you’ll need- 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 preferred
- LPN, LVN, or RN license
- Current knowledge of NCQA and State regulations
- Ability to review clinical information using nationally recognized criteria to determine medical necessity
- Ability to prepare compliant appeal response letters and reviews
- Ability to gather, analyze, and report verbal and written clinical appeal information
- Ability to coordinate Fair Hearings with internal departments and agencies
Benefits
Comp & perks- Competitive pay
- 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
- Equal opportunity employer committed to diversity