Clinical Appeals Coordinator

Position Purpose

Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements.

Key Details

This is a fully remote, work-from-home position open to candidates in the Eastern and Central time zones. The standard schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. ET, with some flexibility based on location. Candidates must hold an active RN license in any U.S. state; a compact license is preferred but not required.

• Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested.
• Prepare reviews for cases that did not meet criteria
• Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up
• Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.
• Maintain files and logs for all appeals
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale
• Maintain current knowledge of NCQA and State regulations
• Coordinate Fair Hearings with various internal departments and agencies
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience

RN with 4+ years of clinical nursing and/or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience.

Managed care or utilization review experience preferred.

License/Certification

LPN, LVN, or RN license (strongly preferred).

Pay Range: $33.71 - $60.67 per hour