Clinical Review Clinician – Appeals (Remote)

About the role

Join Centene’s Medical Management team to evaluate and resolve appeals for a membership of 28 million. This fully remote position works standard business hours (8 a.m. – 6 p.m. CST) and focuses on clinical reviews that determine medical necessity in line with NCQA, state and federal standards.

Key responsibilities

• Conduct clinical reviews of medical records and data to assess appeal validity.
• Prepare detailed case reviews for Medical Directors, researching criteria and appeal basis.
• Ensure timely processing and response to appeals per NCQA, state and federal guidelines.
• Communicate with members, providers, facilities, and internal teams regarding appeal status.
• Generate resolution communications and reports for members and providers.
• Collaborate with leadership to improve consistency, efficiency, and appropriateness of appeal responses.
• Partner with cross‑functional teams to refine appeals processes and prevent recurrence.
• Perform additional duties as assigned.

Required profile

• Graduate of an accredited nursing program (RN preferred) with a valid state or compact RN license.
• 2–4 years of experience in clinical review, utilization management, or related nursing roles.
• Knowledge of NCQA standards, Medicare and Medicaid regulations is preferred.
• Ability to work one weekend day per shift schedule.

Required skills

• NCQA standards
• Medicare regulations
• Medicaid regulations
• Utilization management processes

What we offer

• Competitive hourly pay ranging from $27.02 to $48.55.
• Comprehensive benefits including health insurance, 401(k), stock purchase plan, tuition reimbursement, and paid time off.
• Flexible remote work arrangement.