Clinical Appeals Coordinator
Nebraska Total Care Omaha, Nebraska
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take?
What are the qualities that will help you achieve success in this role at Centene?
- Good listener
Our Medical Roles
Clinical & Nursing Opportunities at Centene
Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Overall Medical Management
A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.
Concurrent Review Nurse
To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.
Prior Authorization Nurse
You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.
Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.
LTSS Program Specialist/Program Specialist Field Based
Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.
You’ll use our data systems to directly assist providers, requesting services and treatments for our members.
To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.
Category Clinical & Nursing
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.
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
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.
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 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.
RN license required within Utilization Management at Superior HealthPlan.
Corporate Requirements: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.
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.
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“Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”- Esmeralda Baig, SVP Operations, Complex Care Products
“I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”- Julie Boulch, Director, Business Implementation Health Plan Initiatives
Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.Honored to be Honored
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“Flexibility is key. Centene is a company of change.”
Started as a Referral Specialist, now a Project Manager IVSee Ashley's career path
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