Remote Clinical Appeals Coordinator, WV


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Business Area: Clinical & Care Management
Job Type: Full time
Date Posted: Feb 11 2024
Job Number: 1476285


You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Centene is a hiring a Clinical Appeals Coordinator. The ideal candida will have a behavioral health background with experience in appeals or concurrent review.

This position is a remote opportunity.

Position Purpose: Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements.

  • Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not meet criteria
  • Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up
  • Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.
  • Maintain files and logs for all appeals
  • Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale
  • Maintain current knowledge of NCQA and State regulations
  • Coordinate Fair Hearings with various internal departments and agencies

Education/Experience: 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.

Corporate & Louisiana Healthcare Connections Requirements: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.

Pay Range: $31.78 – $57.16 per hour

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.