Clinical Appeals Coordinator

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

📋 Description

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

• Ensure that appeal correspondence adheres to State and NCQA standards.

• Assess clinical data for appeals utilizing nationally recognized criteria to evaluate medical necessity.

• Prepare reviews for cases that did not meet established criteria.

• Collect, analyze, and present both verbal and written information regarding clinical appeals from members and providers.

• Draft compliant response letters for clinical appeals from members and providers.

• Keep detailed files and logs for all appeals processed.

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

• Stay updated with current NCQA and State regulations.

• Coordinate Fair Hearings with relevant internal departments and agencies.

• Carry out additional responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• RN with 4+ years of experience in clinical nursing and/or case management.

• LPN/LVN with 5+ years of experience in clinical nursing or case management.

• LPN, LVN, or RN license is strongly preferred.

• Candidates must possess an active RN license in any U.S. state.

• Compact license is preferred, though not mandatory.

• Experience in managed care or utilization review is preferred.

• Availability to work Monday through Friday, from 8:00 a.m. to 5:00 p.m. ET.

• Candidates must reside in the Eastern or Central time zones.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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