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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.
Key Details: This is a remote position. Hours are Monday-Friday 8:00 am - 5:00 pm PST. WA State and/or Compact licensure required. Appeals experience and experience as a lead strongly preferred.
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.
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
Facilitate training, auditing and escalations, and assist with policy and procedure reviews and implementation of new processes
Prepare monthly, quarterly, and annual reports for denials and/or appeals
Coordinate workflows in the department and time off requests to ensure proper coverage
Performs other duties as assigned
Complies with all policies and standards
Education/Experience:
RN with 4+ years of clinical nursing or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Previous experience with Managed care, Case Management or Utilization Review.
License/Certification: Current state RN, LPN, or LVN license.
Pay Range: $33.71 - $60.67 per hour
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is 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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act