RN Licensed Clinical Appeals Coordinator

Acting as the liaison for statewide appeals, the full-time RN Licensed Clinical Appeals Coordinator will ensure compliance with State and NCQA requirements while reviewing clinical information and preparing response letters for member and provider appeals in a fully remote environment. Key responsibilities Review clinical information for appeals to determine medical necessity of requested services Prepare compliant response letters for member and provider clinical appeals Coordinate Fair Hearings and collaborate with Medical Directors on medical determinations Required qualifications Active RN license in any U.S. state; compact license preferred 4+ years of clinical nursing and/or case management experience (or 5+ years for LPN/LVN) Experience in managed care or utilization review preferred Strong understanding of NCQA and State regulations Ability to gather, analyze, and report clinical appeal information