Clinical Appeals Coordinator - Remote

Overview

The Clinical Appeals Coordinator will act as a liaison for statewide appeals and ensure compliance with State and NCQA requirements, while reviewing clinical information for appeals.

In Short

• Act as liaison for statewide appeals and fair hearings.
• Ensure appeal letters comply with State and NCQA requirements.
• Review clinical information to determine medical necessity.
• Prepare response letters for member and provider clinical appeals.
• Maintain files and logs for all appeals.
• Coordinate with Medical Directors for clarifications.
• Maintain knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with internal departments.
• Comply with all policies and standards.
• Perform other duties as assigned.

Requirements

• RN with 4+ years of clinical nursing or LPN with 5+ years experience.
• Managed care or utilization review experience preferred.
• Current RN, LPN, or LVN license required.
• Master’s degree in specialty therapy or equivalent experience preferred.
• 3+ years of therapy services experience in healthcare.
• Current state license in Physical Therapy, Occupational Therapy or Speech-Language Therapy required.

Benefits

• Competitive pay and health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible work schedules including remote options.