RN Clinical Appeals Coordinator

Centene Corporation

1d • $34 - $61

About The Position

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. Applicants must reside in LA and have RN licensure 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 Performs other duties as assigned Complies with all policies and standards Applicants must reside in LA and have RN licensure

Requirements

• Applicants must reside in LA and have RN licensure
• 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.
• Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.

Nice To Haves

• Managed care or utilization review experience preferred.

Responsibilities

• 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
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed