Clinical Appeals Coord

Key Responsibilities

· Manage assigned clinical appeals from intake through resolution, including case review, outreach, documentation gathering, clinical research, matched-specialty coordination, determination support, notification support, and effectuation activities.

· Review appeal files to ensure all required documentation is complete, accurate, and available for review, including denial letters, medical records, benefit information, prior authorization history, claims information, medical policy, clinical criteria, provider submissions, and member or authorized representative statements.

· Apply clinical nursing knowledge, utilization management principles, benefit language, medical policy, and evidence-based criteria to support appropriate case classification and appeal handling.

· Determine whether appeal issues involve medical necessity, benefit coverage, administrative processing, pharmacy, behavioral health, or regulatory concerns, and escalate complex or high-risk cases appropriately.

· Support Appeals Specialists in identifying the appropriate level of review, matched-specialty requirements, reviewer qualifications, and questions for independent physician consultants or Medical Directors.

· Coordinate and document matched-specialty reviews, peer review activity, Medical Director review, external review preparation, and committee review support as required by business process and regulatory requirements.

· Review appeal investigations, case summaries, member and provider contacts, clinical documentation, and system entries to ensure accuracy, completeness, and compliance with internal standards.

· Prepare, review, and support clear written correspondence to members, providers, authorized representatives, and other parties, ensuring communications are accurate, complete, timely, and aligned with regulatory and accreditation requirements.

· Review Level 1 and Level 2 case summaries prior to committee meetings and ensure clinical issues, appeal rationale, medical policy, benefit provisions, and reviewer questions are clearly presented.

· Serve as a clinical resource for Appeals Specialists, Team Leads, Supervisors, Compliance, Medical Directors, Utilization Management, Care Management, Claims, Provider Relations, and other business areas.

· Monitor appeal inventory and case status to support compliance with applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround time requirements.

· Ensure appeal files are audit-ready and include documentation of the substance of the appeal, investigation performed, clinical and benefit review, applicable criteria, reviewer involvement, determination rationale, and required notifications.

· Support implementation of policy, procedure, workflow, system, regulatory, or accreditation changes affecting clinical appeal processing.

· Identify trends, documentation gaps, recurring appeal issues, and opportunities for process improvement, quality improvement, provider education, or upstream utilization management feedback.

· Participate in department training, calibration activities, policy updates, quality reviews, audit preparation, and continuous improvement initiatives.

· Perform all activities in accordance with corporate policies, departmental procedures, privacy requirements, quality standards, regulatory requirements, and accreditation standards.

· Perform other job-related duties as assigned.

Required Qualifications

· Active, unrestricted Registered Nurse license required; Pennsylvania RN license required or preferred based on business need.

· Minimum of five years of clinical nursing experience or equivalent healthcare experience required.

· Experience in utilization management, prior authorization, concurrent review, retrospective review, case management, clinical appeals, grievance and appeals operations, or related managed care operations required or strongly preferred.

· Demonstrated knowledge of clinical appeal processing, medical necessity review, benefit interpretation, medical policy application, and appeal documentation requirements.

· Knowledge of NCQA standards, state and federal appeal regulations, ERISA, ACA, and other regulatory or accreditation requirements applicable to appeal processing.

· Ability to review medical records, clinical documentation, denial rationale, benefit language, medical policy, and utilization management criteria to support accurate appeal handling.

· Strong understanding of health plan operations, including HMO, PPO, self-funded, fully insured, commercial, government program, or delegated vendor processes, as applicable.

· Excellent written and verbal communication skills, including the ability to prepare clear, accurate, member- and provider-facing correspondence.

· Strong analytical, critical-thinking, problem-solving, organizational, and time-management skills.

· Ability to work independently, manage competing priorities, meet regulatory deadlines, and escalate issues appropriately.

· High attention to detail and commitment to documentation quality, member advocacy, regulatory compliance, and audit readiness.

· Proficiency with Microsoft Office products, appeal systems, clinical documentation systems, claims systems, utilization management platforms, databases, and spreadsheet tools.

Preferred Qualifications

· Bachelor of Science in Nursing required.

· Experience in a health plan, managed care organization, third-party administrator, utilization management organization, or delegated clinical review environment preferred.

· Experience with NCQA accreditation audits, state Department of Insurance audits, internal quality audits, client audits, or regulatory file reviews preferred.

· Familiarity with utilization review criteria such as InterQual, MCG, CMS guidance, evidence-based clinical guidelines, corporate medical policy, and plan-specific criteria preferred.

· Experience supporting external review, independent review organization cases, peer review coordination, expedited appeals, complex medical necessity appeals, pharmacy appeals, behavioral health appeals, or benefit appeals preferred.

· Knowledge of Medicare, Medicaid, Commercial, Exchange, ERISA, ACA, and state-specific appeal requirements preferred.

· Experience working with Medical Directors, physician consultants, independent reviewers, Compliance, Legal, Utilization Management, Care Management, Claims, Provider Relations, and Quality teams preferred.

· Experience identifying appeal trends, documentation gaps, overturn drivers, quality issues, or process improvement opportunities preferred.

Key Competencies

· Clinical judgment and utilization management expertise

· Appeal and grievance regulatory knowledge

· NCQA and audit-readiness mindset

· Medical necessity and benefit interpretation

· Evidence-based criteria application

· Strong written communication and documentation quality

· Member and provider advocacy

· Cross-functional collaboration

· Critical thinking and issue escalation

· Organization, prioritization, and deadline management

· Process improvement and quality focus