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Clinical Appeals Coordinator

A Clinical Appeals Coordinator’s primary role is to act as a liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. The Clinical Appeals Coordinator is also responsible for ensuring that all appeal letters that are generated comply with all requirements, whether they be State or NCQA requirements

Job Duties

  • Reviews clinical information for all appeals by using criteria that is nationally recognized, in order to determine the actual necessity of the services that are requested
  • Prepares reviews for cases that do not meet the required criteria
  • Coordinate and deliver verbal and written information regarding patient and provider appeals, and ensure all letters are in line with all required standards
  • Maintains files and logs related to all appeals
  • Coordinates hearings with various internal departments and agencies

Education and Qualifications

  • For some positions, a RN certification is required, or LPN with more experience may be substituted in some situations
  • Generally, at least a few years of clinical nursing or case management experience is required, with more being required for LPN applicants
  • Managed care experience or utilization review experience preferred for some positions