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Grievance & Appeals Nurse
Centene Corporation. Facilitate medical necessity grievance, appeals and denials, including disposition of denial notification letters .
Posted 11/4/2026full-timeRemote • California • United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical necessity grievance and appeals processes, including clinical data review and compliance with NCQA guidelines. Proficient in case review preparation and effective communication with providers and members.
Highest-signal resume keywords
California RN LicensureClinical Nursing ExperienceUtilization ReviewInterQual Criteria KnowledgeAppeals Process Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Medical Necessity ReviewClaims Denial ManagementCase Review PreparationCorrective Action PlanningAppeal Resolution CommunicationClinical Data AnalysisQuality Care IdentificationAdministrative Law Hearing PreparationSystem Authorization EventsPolicy Revision and Creation
Soft Skills
Effective CommunicationProblem-SolvingCollaborationAttention to DetailLiaison Skills
Certifications & Qualifications
California RN LicenseLPN or LVN License
Industry Keywords
NCQA GuidelinesUtilization ManagementGrievance and AppealsClinical Information ReviewQuality Care Concerns
About the role
Key responsibilities & impact- Facilitate medical necessity grievance, appeals and denials, including disposition of denial notification letters
- Review clinical information to determine whether medical necessity criteria are met
- Review clinical data to determine claim payment based on company policies and NCQA guidelines
- Overturn denied claims, uphold denials, and submit cases to the Medical Director for review
- Identify potential quality care concerns through member grievance and potential quality issue case reviews
- Prepare case reviews for the Medical Director when criteria are not met
- Identify system improvements and individual care issues affecting appropriate care or service expectations
- Provide input into corrective action plans for clinical and service events
- Generate appeal resolution communications to members and providers
- Create system authorization events for overturned denial decisions
- Request additional provider information to facilitate timely appeals resolution
- Gather and prepare case information for Administrative Law Hearings
- Maintain the appeals process within NCQA timeframes and the appeals turnaround database
- Assist the Medical Director with revising, updating, or creating policies to satisfy NCQA and contractual requirements
- Act as liaison between providers and the business to resolve issues
- Perform other assigned duties and comply with policies and standards
Requirements
What you’ll need- Candidate must hold California RN Licensure
- LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience
- Experience with utilization or appeals review preferred
- Knowledge of InterQual criteria preferred
- Current state's RN, LPN, or LVN license
- Must be licensed in CA
- Must work PST hours
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