Clinical Review Clinician – Appeals

Centene Corporation

Clinical appeals clinician reviewing medical records and medical necessity for Centene’s healthcare coverage programs. Preparing resolutions and supporting compliant appeals processes remotely.

Posted 9/2/2026full-timeRemote • Illinois, Louisiana, Mississippi, Montana, Texas • 🇺🇸 United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical reviews and appeals processing, ensuring compliance with NCQA, Medicare, and Medicaid standards. Proficient in analyzing medical records and collaborating with interdepartmental teams to enhance clinical appeal processes.

Highest-signal resume keywords

Clinical ReviewNCQA StandardsMedical Necessity DeterminationBehavioral Health ExperienceUtilization Management Processes

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewAppeals ProcessingCase Review PreparationData AnalysisClinical Data Evaluation

Soft Skills

Effective CommunicationInterdepartmental CollaborationProblem Solving

Certifications & Qualifications

LPN LicensureLVN LicensureRN State LicensureLCSWLMHCLPCLMFTLicensed Psychologist

Industry Keywords

Medicare RegulationsMedicaid RegulationsUtilization ManagementClinical AppealsAppeal Requests

About the role

Key responsibilities & impact

Perform clinical reviews to resolve and process appeals
Review medical records and clinical data to determine medical necessity according to policies, guidelines, and NCQA standards
Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing appeal bases
Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards
Communicate with members, providers, facilities, and other departments regarding appeal requests
Generate appeals resolution communications and reports for members and providers
Work with leadership to improve consistency, efficiency, and appropriateness of appeal responses
Partner with interdepartmental teams to improve clinical appeals processes and prevent recurrences
Perform other assigned duties and comply with company policies and standards

Requirements

What you’ll need

Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
2–4 years of related experience
Fully licensed with one of the approved licenses/certifications
LPN state licensure, or LVN licensure, or RN state/compact-state licensure, or LCSW, LMHC, LPC, LMFT, or Licensed Psychologist license
Knowledge of NCQA, Medicare and Medicaid regulations preferred
Knowledge of utilization management processes preferred
Behavioral health experience strongly preferred
Availability Monday–Friday, 8:00 am–5:00 pm CST, with weekend on-call rotations and holiday rotation

Benefits

Comp & perks

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
additional forms of incentives may be included in total compensation