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.

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.
• 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

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.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.