Clinical Appeals Coordinator

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

📋 Description

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

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

• Evaluate clinical data for appeals utilizing nationally accepted criteria to assess medical necessity.

• Prepare reviews for cases that fail to meet established criteria.

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

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

• Maintain comprehensive files and logs for all appeals.

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

• Coordinate Fair Hearings with internal departments and external agencies.

• Execute other responsibilities as assigned.

• Adhere to all organizational policies and standards.

⛳️ Requirements

• Must hold a license in Wisconsin.

• RN with 4+ years of clinical nursing and/or case management experience, or LPN/LVN with 5+ years of clinical nursing or case management experience.

• Experience in managed care or utilization review is highly preferred.

• Valid LPN, LVN, or RN license.

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

• For specialty therapy, a Master’s degree in the relevant field or equivalent experience is required.

• For specialty therapy, a minimum of 3 years of experience providing therapy services in healthcare or home health environments is necessary.

• Current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy is required.

• Speech-Language Therapists must possess an active Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

• For Corporate & Louisiana Healthcare Connections: Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license is required.

• Keep updated on NCQA and State regulations.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional forms of incentives may be included in total compensation.