Lead Clinical Appeals Coordinator

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

📋 Description

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

• Ensure that appeal letters meet both State and NCQA guidelines.

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

• Prepare reviews for cases that do not satisfy the criteria.

• Collect, analyze, and report both verbal and written information concerning member and provider clinical appeals.

• Draft compliant response letters for member and provider clinical appeals.

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

• Stay updated on current NCQA and State regulations.

• Coordinate Fair Hearings with internal teams and agencies.

• Lead training sessions, audits, and escalations.

• Support the review of policies and procedures and the implementation of new processes.

• Prepare monthly, quarterly, and annual reports pertaining to denials and/or appeals.

• Manage department workflows and time-off requests to ensure adequate coverage.

• Execute other duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Registered Nurse (RN) with over 4 years of clinical nursing 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.

• Prior experience in Managed Care, Case Management, or Utilization Review.

• Valid and current state RN, LPN, or LVN license.

• WA State and/or Compact licensure is required.

• Experience with appeals and a lead role is strongly preferred.

• Availability to work Monday through Friday, from 8:00 am to 5:00 pm PST.

• Familiarity with NCQA and State regulations.

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

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in the overall compensation package.

• An equal opportunity employer dedicated to fostering diversity.