Clinical Review Clinician - Appeals at Centene

This role is designed for experienced clinical professionals—specifically Registered Nurses (RN/LVN/LPN) or Licensed Mental Health Clinicians (LCSW/LPC/LMHC)—who possess a strong background in medical necessity determination. The ideal candidate has 2–4 years of experience and excels at navigating complex medical records to evaluate appeals against regulatory and clinical guidelines. As a fully remote position based in Texas, this role offers significant workplace flexibility. You will act as a critical bridge between medical data and final determinations, preparing cases for Medical Directors and ensuring compliance with NCQA and Medicare/Medicaid standards. Centene provides a robust benefits package, including a stock purchase plan and tuition reimbursement, making it a strong choice for those seeking long-term stability in the managed care sector. **You might be a good fit if you...** * Hold an active nursing or clinical mental health license (RN, LVN, LCSW, LPC, etc.). * Have a sharp eye for detail and enjoy researching medical records to build a case. * Are comfortable working within strict state and federal timelines for appeal resolutions. * Have prior experience with Utilization Management or knowledge of NCQA standards.