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: Must be licensed in Wisconsin. Experience in healthcare, managed care, utilization management, appeals, grievances, case management, or related healthcare operations highly preferred.

• 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.

Texas Requirements: RN license required within Utilization Management at Superior HealthPlan or LPC, LCSW or Psy D. licensure within UM Behavioral Health Appeals team.

Specialty Therapy Requirement: Master's degree in area of specialty therapy or equivalent experience. 3+ years of experience providing therapy services in healthcare or home health settings. Managed care or utilization review experience preferred.

Licenses/Certifications: Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy. Speech-Language Therapist must have an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Corporate & Louisiana Healthcare Connections Requirements: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.

Pay Range: $33.71 - $60.67 per hour