Clinical Appeals Coordinator

This is a fully remote position, open to applicants in California, +2 more states.

📋 Description

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

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

• Evaluate clinical information based on nationally recognized criteria to assess medical necessity.

• Prepare reviews for cases that do not meet the established criteria.

• Collect, analyze, and present both verbal and written information related to member and provider clinical appeals.

• Follow up on the status of appeal information.

• Draft response letters addressing member and provider clinical appeals.

• Keep organized files and logs for all appeals submitted.

• Collaborate with Medical Directors to clarify medical determinations or clinical justifications.

• Stay updated on NCQA and State regulations.

• Coordinate Fair Hearings with relevant internal departments and agencies.

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

• Experience in managed care or utilization review is preferred.

• Valid LPN, LVN, or RN license.

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

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

• For Specialty Therapy: A minimum of 3 years of experience delivering therapy services in healthcare or home health environments.

• For Specialty Therapy: Current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy.

• For Speech-Language Therapist: Must hold an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

• For Corporate & Louisiana Healthcare Connections: Must possess a current state RN, LPN, or LVN, LPC, LCSW, or Psy.D. license.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Potential additional incentives included in total compensation.