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Centene Corporation Clinical Appeals Coordinator in Des Moines, Iowa

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. 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. TITLE: Clinical Appeals Coordinator LOCATION: Des Moines, Iowa REQNUMBER: 1216721 COMPANY: Clinical & Care Management POSITION TYPE: Both

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