Clinical Coordinator

• Act as liaison for statewide appeals, fair hearings, review organizations, and other external appeals
• Ensure appeal letters comply with State and NCQA requirements
• Review clinical information for appeals using nationally recognized criteria to determine medical necessity
• Prepare reviews for cases that did not meet criteria
• Gather, analyze, and report verbal and written information regarding member and provider clinical appeals, including follow-up
• Prepare response letters for member and provider clinical appeals
• Maintain files and logs for all appeals
• Coordinate with Medical Directors to clarify medical determinations or clinical rationale
• Coordinate Fair Hearings with internal departments and agencies
• Perform other duties as assigned
• Comply with all policies and standards

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