Clinical Appeals Coordinator

Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements. Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not meet criteria. Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards. Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale. Maintain current knowledge of NCQA and State regulations. Coordinate Fair Hearings with various internal departments and agencies.

According to JobzMall, the average salary range for a Clinical Appeals Coordinator in 5130 Sunforest Dr, Tampa, FL 33634, USA is $50,000 - $60,000.

Centene Corporation is a large publicly traded company and a multi-line managed care enterprise that serves as a major intermediary for both government-sponsored and privately insured health care programs.