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Lead Clinical Appeals Coordinator
Centene Corporation. Act as 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 processes, compliance with NCQA and State regulations, and effective communication with medical directors and external organizations.
Highest-signal resume keywords
RN LicenseClinical Nursing ExperienceCase Management ExperienceNCQA KnowledgeAppeals 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
Medical Necessity ReviewClinical Information AnalysisReport PreparationPolicy ImplementationWorkflow Coordination
Soft Skills
CommunicationTraining FacilitationAnalytical Thinking
Certifications & Qualifications
Current State RN LicenseWA State Licensure
Industry Keywords
Managed CareUtilization ReviewFair HearingsClinical AppealsCompliance Standards
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
- 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
What you’ll need- 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
Comp & perks- 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