Clinical Appeals Coordinator

Centene
Oregon
Workplace: RemoteFull timeUSD 33.71 - 60.67 hourlyFunction: Executive & General ManagementExperience: 4+ yearsEducation: mastersSkills: ["Attention to detail","Analysis","Communication","Documentation","Regulatory compliance"]

Coordinate statewide clinical appeals, fair hearings, and reviews for members and providers. Review appeals using nationally recognized criteria to determine medical necessity, prepare compliant review and response letters, and maintain accurate appeal files and logs. Gather and analyze verbal and written appeal information, follow up with relevant parties, and coordinate with Medical Director(s) to clarify determinations and clinical rationale while staying current on NCQA and state regulations.

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FursaFursa
Centene
Centene
4 days ago

Clinical Appeals Coordinator

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Last checked: 3 hours agoStatus: Live

Job Summary

Coordinate statewide clinical appeals, fair hearings, and reviews for members and providers. Review appeals using nationally recognized criteria to determine medical necessity, prepare compliant review and response letters, and maintain accurate appeal files and logs. Gather and analyze verbal and written appeal information, follow up with relevant parties, and coordinate with Medical Director(s) to clarify determinations and clinical rationale while staying current on NCQA and state regulations.
Location: Oregon
Workplace: Remote
Employment Type: Full time
Job Function: Executive & General Management

Key Responsibilities

  • •Act as the statewide liaison for appeals, fair hearings, review organizations, and external appeals.
  • •Review clinical information using nationally recognized criteria to determine medical necessity.
  • •Prepare reviews and response letters when cases do not meet criteria, ensuring compliance with State and NCQA standards.
  • •Gather, analyze, and report verbal and written appeal information, including conducting information follow-up.
  • •Maintain appeal files and logs and coordinate with Medical Director(s) for clarification of determinations or clinical rationale.

Pay and Benefits

Salary: USD 33.71 - 60.67 hourly
Perks:Health Insurance401kPaid LeaveRemote Work

Key Requirements

  • •RN with 4+ years of clinical nursing and/or case management experience (or LPN/LVN with 5+ years).
  • •Managed care or utilization review experience preferred.
  • •LPN, LVN, or RN license.
  • •Prepare and ensure appeal letters meet State and NCQA requirements.
  • •Master’s degree in area of specialty therapy or equivalent experience, with 3+ years providing therapy services in healthcare or home health settings (managed care/utilization review preferred).
Experience:4+ yearsHealthcareManaged careUtilization reviewCase management
Education:Master's
Skills:Attention to detailAnalysisCommunicationDocumentationRegulatory compliance
Licenses:RNLPNLVN

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn