Grievance and Appeals Nurse – State

Centene Corporation

California-licensed nurse reviewing medical necessity grievances, appeals, and denials for Centene. Evaluating clinical data, resolving appeals, and supporting quality-of-care decisions.

Posted 8/18/2026full-timeRemote • California • 🇺🇸 United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity grievances, appeals, and denials, with a strong understanding of NCQA guidelines and clinical review processes. Proficient in preparing case reviews and generating appeal resolution communications while maintaining compliance with state regulations and company policies.

Highest-signal resume keywords

LPN Or LVN LicenseRN LicenseClinical Nursing ExperienceUtilization Review ExperienceKnowledge Of NCQA Guidelines

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewClaims Denial ManagementClinical Data AnalysisAppeals Process ManagementCase Review PreparationCorrective Action PlanningInterQual Criteria KnowledgeAdministrative Law Hearing PreparationSystem Authorization EventsQuality Of Care Assessment

Soft Skills

Communication SkillsProblem-Solving SkillsInterpersonal SkillsAttention To DetailOrganizational Skills

Industry Keywords

NCQAUtilization ManagementGrievance ProcessClinical PoliciesCalifornia State License

About the role

Key responsibilities & impact

Facilitate medical necessity grievances, appeals, and denials, including disposition of denial notification letters
Review clinical information to determine whether medical necessity criteria are met
Review clinical data to determine claim payment based on company policies and NCQA guidelines
Overturn denied claims, uphold denials, and submit cases to the Medical Director for review
Identify potential quality-of-care concerns through member grievance and potential quality issue reviews
Prepare case reviews for the Medical Director when criteria are not met
Identify system improvements and individual care issues affecting appropriate care or service expectations
Provide input into corrective action plans for clinical and service events
Generate appeal resolution communications to members and providers
Create system authorization events for overturned denial decisions
Request additional provider information to facilitate timely appeals resolution
Gather and prepare case information for Administrative Law Hearings
Maintain the appeals process within NCQA timeframes and the appeals turnaround database
Assist the Medical Director with revising, updating, or creating policies to satisfy NCQA and contractual requirements
Act as liaison between providers and the business to resolve issues
Perform other duties as assigned
Comply with all policies and standards

Requirements

What you’ll need

LPN or LVN with 3+ years of clinical nursing experience
RN with 2+ years of clinical nursing experience
Current state RN, LPN, or LVN license
Must be licensed in California
Experience with utilization or appeals review preferred
Knowledge of InterQual criteria preferred
Ability to work PST hours
Knowledge of company policies and NCQA guidelines

Benefits

Comp & perks

Competitive benefits
Competitive pay
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules