Clinical Appeals Coordinator

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Serve as the primary contact for all statewide appeals, fair hearings, review organizations, and other external appeals.

• Ensure that all generated appeal letters adhere to both State and NCQA standards.

• Evaluate clinical information for appeals using nationally accepted criteria to assess the medical necessity of requested services.

• Prepare reviews for cases that have not met the established criteria.

• Collect, analyze, and document verbal and written information related to member and provider clinical appeals, including follow-up actions.

• Draft response letters for member and provider clinical appeals, ensuring compliance with State and NCQA guidelines.

• Maintain comprehensive files and logs for all appeals.

• Collaborate with Medical Director(s) to clarify medical determinations or clinical rationale as needed.

• Stay up-to-date with NCQA and State regulations.

• Coordinate Fair Hearings in conjunction with internal departments and agencies.

• Perform other assigned duties as required.

• Adhere to all policies and standards.

⛳️ Requirements

• RN with a minimum of 4 years of clinical nursing and/or case management experience.

• Alternatively, LPN/LVN with at least 5 years of clinical nursing or case management experience.

• Valid LPN, LVN, or RN license.

• Specialty Therapy Requirement: Master’s degree in a relevant area of specialty therapy or equivalent experience.

• At least 3 years of experience providing therapy services in healthcare or home health environments.

• Managed care or utilization review experience is preferred.

• Ability to review clinical information using nationally recognized criteria.

• Maintain familiarity with NCQA and State regulations.

🏝️ Benefits

• Competitive pay.

• Health insurance coverage.

• 401K plans.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Additional incentive programs may be included in total compensation.