WA State Licensed Clinical Appeals Coordinator

Job Summary

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

Key responsibilities

• Review clinical information for appeals using nationally recognized criteria to determine medical necessity
• Prepare response letters for clinical appeals, ensuring compliance with State and NCQA standards
• Coordinate Fair Hearings and facilitate training and auditing processes within the department

Required qualifications

• Current state RN, LPN, or LVN license
• RN with 4+ years or LPN/LVN with 5+ years of clinical nursing or case management experience
• Previous experience with Managed Care, Case Management, or Utilization Review
• Strong preference for candidates with appeals experience and leadership background
• Knowledge of NCQA and State regulations