Clinical Appeals Coordinator (RN/NP/PA) - Remote Eligible

Capital District Physicians Health Plan Inc; City of Utica (NY); Hybride; USD 62 000 - 129 000; Plein temps

Résumé du poste

Capital District Physicians Health Plan Inc is seeking an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, you will review medical necessity requests and expedite cases within regulatory requirements.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate decisions while managing multiple regulatory timeframes.

Qualifications

• RN/PA/NP license with minimum 3 years clinical experience and 1 year in quality/utilization review; or LPN with 3 years appeals experience.
• Experience in research, data analysis, ICD/CPT coding, DRG principles; appeals processing preferred.
• Basic computer skills; ability to navigate multiple systems simultaneously.
• Demonstrates intermediate organizational and problem-solving skills; ability to multi-task and prioritize.

Responsabilités

• Research and interpret member and provider appeals, grievances, and complaints; review medical records, contracts, and policies.
• Prepare clear written and verbal case responses using templates and communicate clinical decisions.
• Perform clinical reviews of quality-of-care cases and report findings to leadership and regulatory bodies as required.
• Manage inventory and escalate concerns to Leadership to meet regulatory timelines.

Connaissances

Clinical review

Data analysis

Multi-tasking

Organizational skills

Problem solving

Communication

Formation

RN, PA, or NP license

LPN with appeals experience

Description du poste

Capital District Physicians Health Plan Inc is seeking an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, you will review medical necessity requests and expedite cases within regulatory requirements.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate decisions while managing multiple regulatory timeframes.