About This Role
The Clinical Appeals Coordinator acts as the liaison for statewide appeals, ensuring compliance with State and NCQA requirements. This fully remote position is ideal for candidates with clinical nursing or case management experience.
Highlights
- Pay: $33.71 - $60.67/hour
- Location: Remote, DE
- Schedule: Full-time, Day shift
What You'll Do
- Review clinical information for all appeals utilizing nationally recognized criteria.
- Prepare reviews for cases that did not meet criteria.
- Gather, analyze, and report information regarding member and provider clinical appeals.
- Prepare response letters for clinical appeals ensuring compliance with standards.
- Maintain files and logs for all appeals.
- Coordinate with Medical Director(s) to clarify medical determinations.
- Maintain current knowledge of NCQA and State regulations.
- Coordinate Fair Hearings with various internal departments and agencies.
- Perform other duties as assigned.
- Comply with all policies and standards.
Requirements
Education:
- 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.
Experience:
- Managed care or utilization review experience preferred.
Licenses & Certifications:
- Active RN license in any U.S. state required; compact license preferred.
- LPN or LVN license strongly preferred.
Benefits
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible work schedules
About Centene
Centene is a leading healthcare provider committed to delivering exceptional patient care. They connect people to the care they need to live healthier lives, making a real impact every day through meaningful work.
#J-18808-Ljbffr
