Clinical Appeals Specialist
4 days ago
Join Centene Corporation, a leading healthcare company, as a Clinical Appeals Coordinator and play a vital role in ensuring our members receive the best possible care.
Job Summary:We are seeking a highly skilled and detail-oriented Clinical Appeals Coordinator to join our Medical Management/Health Services team. As a Clinical Appeals Coordinator, you will be responsible for reviewing clinical information, preparing appeal letters, and ensuring compliance with state and NCQA requirements.
Key Responsibilities:- Review clinical information for appeals and determine medical necessity of services requested
- Prepare appeal letters and ensure compliance with state and NCQA standards
- 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
To be successful in this role, you will need:
- 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
- LPN, LVN, or RN license
Centene Corporation offers a comprehensive benefits package, including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off, and a flexible approach to work with remote, hybrid, field, or office work schedules.
We are an equal opportunity employer committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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Clinical Nurse Specialist ICU
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Clinical Care Specialist
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Advanced Clinical Nurse Specialist
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Sanitation Services Specialist
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Clinical Research Specialist
2 weeks ago
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Clinical Nurse Specialist
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