Clinical Appeals Coordinator/ Tuesday-Saturday Work Schedule
Posted on Dec 8, 2018 by Centene Corporation
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 criteriaGather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow upPrepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.Maintain files and logs for all appealsCoordinate with Medical Director(s) to clarify medical determinations or clinical rationaleMaintain current knowledge of NCQA and State regulationsCoordinate Fair Hearings with various internal departments and agenciesQualification:
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\:Education/Experience\: Graduate from an Accredited School of Nursing. 4+ years of clinical nursing and/or case management experience. Managed care or utilization review experience preferred.License/Certification\: RN License required.Specialty Therapy RequirementMasterâs 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.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.