Lead 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 remote position. Hours are Monday-Friday 8:00 am - 5:00 pm PST. WA State and/or Compact licensure required. Appeals experience and experience as a lead strongly 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.
• 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
• Facilitate training, auditing and escalations, and assist with policy and procedure reviews and implementation of new processes
• Prepare monthly, quarterly, and annual reports for denials and/or appeals
• Coordinate workflows in the department and time off requests to ensure proper coverage
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience

RN with 4+ years of clinical nursing or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Previous experience with Managed care, Case Management or Utilization Review.

License/Certification

Current state RN, LPN, or LVN license.

Pay Range: $33.71 - $60.67 per hour