Clinical Appeals Coordinator - Pennsylvania; Remote

Clinical Appeals Coordinator

Location:

Pennsylvania (Remote) Duration: 3+ Months (Possible FT Conversion) Pay rate: $45/hr

This is a fully remote position but candidates must reside in PA, NJ, or DE for conversion potential. PA RN license or compat license to include PA is required. Candidates must have a laptop and preferably 1-2 monitors if possible for this position. Rotation of Saturday hours and holiday hours - will only be 8am-1pm if on rotation.

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 time frames. 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 Inter Qual or MCG.

• 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…