Clinical Review Clinician – Appeals

Centene Corporation

Clinical Review Clinician managing medical necessity reviews in the appeals process for a national health services organization. Work includes collaborating with medical directors and ensuring compliance with healthcare standards.

Posted 7/9/2026full-timeRemote • Arizona, Kansas, New York, Ohio, Texas • 🇺🇸 United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite

About the role

Key responsibilities & impact

Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards
Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned
Complies with all policies and standards

Requirements

What you’ll need

Graduate from an Accredited School of Nursing or Master's degree in related Behavioral/Counseling field
minimum of 2 – 4 years of related experience
6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred
Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred
Knowledge of NCQA, Medicare and Medicaid regulations preferred
Knowledge of Utilization Management principles and processes preferred
Strong communication, attention to detail, organizational and time management skills
Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone)
Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams)

Benefits

Comp & perks

competitive pay
health insurance
401K and stock purchase plans
tuition reimbursement
paid time off plus holidays
flexible approach to work with remote, hybrid, field or office work schedules

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Clinical Data AnalysisMedical Necessity DeterminationCase Review PreparationBehavioral Health ManagementPsychiatric Nursing

Soft Skills

Strong CommunicationAttention to DetailOrganizational SkillsTime Management

Certifications

Graduate from Accredited School of NursingMaster's Degree in Related Behavioral/Counseling Field