Texas Licensed Clinical Appeals Coordinator

Job Summary

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

Key responsibilities

• Review clinical information for appeals to determine medical necessity using nationally recognized criteria
• Prepare response letters for member and provider clinical appeals, ensuring compliance with State and NCQA standards
• Coordinate Fair Hearings and maintain files and logs for all appeals

Required qualifications

• 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
• Current state RN, LPN, or LVN license
• Managed care or utilization review experience preferred
• Master's degree in a specialty therapy area or equivalent experience, with 3+ years providing therapy services in healthcare or home health settings
• Current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy, if applicable