Clinical Appeals Coordinator

Independence Blue Cross; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Independence Blue Cross is seeking a Clinical Appeals Coordinator, RN to manage end-to-end clinical appeals including medical necessity, benefit, pharmacy, and behavioral health issues. You will apply nursing judgment, utilization management knowledge, and evidence-based criteria to ensure timely, compliant reviews.

This role serves as a clinical resource to Appeals Specialists, team leads, supervisors, and medical directors, supporting case development, outreach, and audit-ready file

Qualifications

• Active, unrestricted RN license required.
• Minimum five years of clinical nursing experience.
• Experience in utilization management and appeal processing.
• Knowledge of NCQA standards and appeal regulations.
• Ability to review medical records and documentation.

Responsibilities

• Manage assigned clinical appeals from intake through resolution.
• Review appeal files for completeness and accuracy.
• Apply clinical nursing knowledge to support classification and handling.
• Coordinate matched-specialty reviews and committee support.
• Prepare clear member/provider communications.

Skills

Registered Nurse

Utilization management

Clinical documentation

Evidence-based review

Strong communication

Tools

Microsoft Office

EMR systems

Appeal systems

Job description

The Clinical Appeals Coordinator, RN is responsible for supporting the end-to-end processing of clinical appeals, including medical necessity, benefit, pharmacy, behavioral health, and administrative appeal issues, as applicable. This role applies clinical nursing judgment, utilization management knowledge, benefit interpretation, medical policy, and evidence-based review criteria to ensure appeals are reviewed accurately, thoroughly, and within applicable regulatory, accreditation, and contractual timeframes.

The Clinical Appeals Coordinator serves as a clinical resource to Appeals Specialists, Team Leads, Supervisors, Medical Directors, peer reviewers, and cross-functional partners. The role supports case development, documentation review, matched-specialty coordination, member and provider outreach, appeal correspondence, committee preparation, and audit-ready file completion. The ideal candidate has experience in utilization management and/or appeal processing, strong knowledge of NCQA standards and state/federal appeal requirements, and familiarity with utilization review criteria such as InterQual or MCG.

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 upscale 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.
• 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 escape 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.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group together with its subsidiaries is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.