Clinical Appeals Coordinator
Core
Act as a liaison for statewide appeals and fair hearings, reviewing clinical information to determine medical necessity and ensuring compliance with State and NCQA requirements.
Role type
Clinical Appeals Coordinator
Builds
Compliant appeal response letters and case review documentation for members and providers
Domain
Healthcare / Utilization Review
Deliverable
client delivery
Required skills
Clinical nursing judgment, case management, medical necessity determination, regulatory compliance analysis, file management, cross-department coordination
Preferred skills
Managed care experience, utilization review experience
Technologies
None stated
Responsibilities
Review clinical information for appeals to determine medical necessity; Prepare reviews for cases not meeting criteria; Gather and report information on member and provider appeals; Prepare compliant response letters; Maintain appeal files and logs; Coordinate fair hearings with internal departments and agencies
Seniority
Mid-level, hands-on IC
