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
Education/Experience:
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.
License/Certification: LPN, LVN, or RN license.
Texas Requirements: RN license required within Utilization Management at Superior HealthPlan or LPC, LCSW or Psy D. licensure within UM Behavioral Health Appeals team.
Specialty Therapy Requirement: Master’s degree in area of specialty therapy or equivalent experience. 3+ years of experience providing therapy services in healthcare or home health settings. Managed care or utilization review experience preferred.
Licenses/Certifications: Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy. Speech-Language Therapist must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.
Corporate & Louisiana Healthcare Connections Requirements: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D 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
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