Clinical Appeals Coordinator

This is a fully remote position, open to applicants in Kansas.

📋 Description

• Serve as a point of 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 for appeals utilizing nationally recognized criteria to assess medical necessity.

• Prepare reviews for cases that do not fulfill criteria.

• Collect, analyze, and report on information related to member and provider clinical appeals, including follow-up actions.

• Draft response letters for member and provider clinical appeals.

• Keep comprehensive files and logs for all appeals.

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

• Stay updated on NCQA and State regulations.

• Organize Fair Hearings with internal departments and agencies.

• Execute other assigned tasks while adhering to policies and standards.

⛳️ Requirements

• Registered Nurse (RN) with over 4 years of clinical nursing and/or case management experience, or Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) with more than 5 years of clinical nursing or case management experience.

• Experience in managed care or utilization review is preferred.

• Valid LPN, LVN, or RN license.

• Up-to-date knowledge of NCQA and State regulations.

• Capability to review clinical information using nationally recognized criteria to assess medical necessity.

• Proficiency in preparing compliant appeal response letters and reviews.

• Skill in gathering, analyzing, and reporting both verbal and written clinical appeal information.

• Ability to coordinate Fair Hearings with internal departments and agencies.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off in addition to holidays.

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

• Additional incentive opportunities may be included in total compensation.

• Equal opportunity employer dedicated to promoting diversity.