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Clinical Appeals Coordinator
Centene Corporation. Act as the liaison for statewide appeals, fair hearings, review organizations, and other external appeals .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical nursing and case management, with a strong focus on appeals processing, compliance with NCQA and State regulations, and effective communication with medical directors and external organizations.
Highest-signal resume keywords
RN LicenseClinical Nursing ExperienceCase Management ExperienceManaged Care ExperienceUtilization Review Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Appeals ProcessingClinical ReviewMedical Necessity DeterminationCompliance DocumentationData Analysis
Soft Skills
CommunicationCoordinationAnalytical Thinking
Certifications & Qualifications
Active RN LicenseLPN LicenseLVN License
Industry Keywords
NCQA RequirementsState RegulationsFair HearingsClinical AppealsMedical Determinations
About the role
Key responsibilities & impact- Act as the 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
- 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 duties as assigned
- Comply with all policies and standards
Requirements
What you’ll need- RN with 4+ years of clinical nursing and/or case management experience
- LPN/LVN with 5+ years of clinical nursing or case management experience
- LPN, LVN, or RN license (strongly preferred)
- Candidates must hold an active RN license in any U.S. state
- Compact license preferred but not required
- Managed care or utilization review experience preferred
- Ability to work Monday through Friday, 8:00 a.m. to 5:00 p.m. ET
- Candidates must be located in the Eastern or Central time zones
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