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Clinical Appeals Coordinator, Remote Louisiana

Company: LA Healthcare Connections
Location: Baton Rouge
Posted on: January 13, 2022

Job Description:

You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you'll have access to 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 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 agenciesOur Comprehensive Benefits Package:Flexible work solutions including remote options, hybrid work schedules and dress flexibilityCompetitive payPaid Time Off including paid holidaysHealth insurance coverage for you and dependents401(k) and stock purchase plansTuition reimbursement and best-in-class training and development 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.Specialty Therapy RequirementMaster'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.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.

Keywords: LA Healthcare Connections, Baton Rouge , Clinical Appeals Coordinator, Remote Louisiana, Healthcare , Baton Rouge, Louisiana

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