Clinical Appeals Coordinator
Posted 17ds ago
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Job Description
Clinical Appeals Coordinator roles include investigating medical necessity requests for a health plan. Collaborating with medical management while ensuring compliance with appeals and grievances standards.
Responsibilities:
- Investigate and process medical necessity requests from both members and providers
- Conduct and lead investigations and reviews for member and provider medical necessity appeals
- Review the medical record of denied services for medical necessity
- Provide a summary of case for the medical director, and other partners in the health plan care team
- Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements
- Document and log case information for the appeal
- Generate the written response to the member or provider
- Serve as a subject matter expert for appeals and grievances
Requirements:
- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license
- Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC)
- Three (3) years of clinical experience
- Three (3) years’ experience with clinical claims processing and review
- Three (3) years’ experience working with appeal and grievances
- Two (2) years’ customer service experience
- Bachelor of Science in Nursing (preferred)
- Medical Management experience (preferred)
Benefits:
- Standard office environment
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