RN Licensed Clinical Appeals Coordinator

Job Summary

Acting as the liaison for statewide appeals, the full-time RN Licensed Clinical Appeals Coordinator will ensure compliance with State and NCQA requirements while reviewing clinical information and preparing response letters for member and provider appeals in a fully remote environment.

Key responsibilities

• Review clinical information for appeals to determine medical necessity of requested services
• Prepare compliant response letters for member and provider clinical appeals
• Coordinate Fair Hearings and collaborate with Medical Directors on medical determinations

Required qualifications

• Active RN license in any U.S. state; compact license preferred
• 4+ years of clinical nursing and/or case management experience (or 5+ years for LPN/LVN)
• Experience in managed care or utilization review preferred
• Strong understanding of NCQA and State regulations
• Ability to gather, analyze, and report clinical appeal information