Care Coordinator – Clinical Appeals RN

This is a fully remote position, open to applicants in Alaska, +26 more states.

📋 Description

• Conduct prospective, admission, concurrent, and retrospective evaluations of medical necessity.

• Evaluate the medical appropriateness of inpatient admissions, outpatient services, procedures, benefit applications, and requests from out-of-network providers.

• Collaborate with Medical Directors when care fails to meet established criteria or medical policies.

• Thoroughly document clinical information in a complete, accurate, and timely manner.

• Achieve or surpass production and quality targets.

• Utilize provider contracts, member contracts, authorization prerequisites, Milliman Care Guidelines, and medical policies effectively.

• Identify opportunities within Clinical Programs and refer members to suitable healthcare initiatives.

• Work in conjunction with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services.

• Ensure that utilization management decisions and timeliness standards adhere to accreditation and regulatory requirements.

• Engage in quality improvement initiatives, process evaluations, and various projects.

⛳️ Requirements

• Bachelor’s degree or a minimum of four (4) years of relevant work experience (REQUIRED).

• Active State Licensure as a registered nurse (REQUIRED).

• A minimum of three (3) years of clinical experience (REQUIRED).

• Experience in Utilization Management.

• Background in the health plan industry.

• Availability to work Monday through Friday, from 8:00 AM to 5:00 PM Pacific Time.

• Must reside in one of the designated hiring states, subject to role or city limitations.

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage with minimal employee premiums.

• Optional benefits, including pet insurance.

• Life and disability insurance offerings.

• Retirement plans, featuring a 401K employer match.

• Pension plan that vests after three years of service.

• Wellness incentives and mental health resources, including counseling, stress management, and mindfulness programs.

• Generous paid time off policy.

• Tuition assistance for both undergraduate and graduate degrees.

• Employee recognition initiatives.

• Commuter benefits.

• Complimentary convenient on-site parking.

• Subsidized on-campus dining options.

• On-site health and wellness activities.

• Fitness and well-being center offering both in-person and virtual workouts, along with nutritional counseling.