Wisconsin Licensed Clinical Appeals Coordinator

Job Summary

To support statewide appeals and ensure compliance with State and NCQA requirements, the full-time Wisconsin Licensed Clinical Appeals Coordinator will manage clinical information reviews, prepare compliant response letters, and coordinate Fair Hearings while working remotely.

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 regulations
• Coordinate with Medical Directors and maintain knowledge of NCQA and State regulations

Required qualifications

• Current RN, LPN, or LVN license in Wisconsin
• 4+ years of clinical nursing or case management experience for RN or 5+ years for LPN/LVN
• Experience in managed care, utilization management, or healthcare operations preferred
• Ability to gather, analyze, and report clinical information effectively
• Familiarity with NCQA and State regulations related to clinical appeals