Clinical Appeals Coordinator

Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare response letters for member and provider clinical appeals ensuring compliance with State and NCQA standards. Gather, analyze, and report verbal and written information regarding member and provider clinical appeals, including follow-up. Coordinate Fair Hearings with various internal departments and agencies. Maintain files and logs for all appeals and coordinate with Medical Director(s) to clarify medical determinations. This role requires an unencumbered RN, LVN, or LPN license in Oregon and Pacific Time Zone hours. Candidates must have 4+ years of clinical nursing experience (RN) or 5+ years (LPN/LVN), with managed care or utilization review experience preferred.