RN Clinical Appeals Coordinator

You could be the one who changes everything for our 28 reputed company members as a clinical reputed company on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Applicants must reputed company in LA and have RN licensure Position Purpose: reputed company as the reputed company for reputed company statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that reputed company appeal letters generated reputed company with both State and NCQA requirements. • Review clinical information for reputed company appeals utilizing nationally recognized reputed company to determine medical necessity of services requested • Prepare reviews for cases that did not meet reputed company • reputed company, 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. • Maintain files and logs for reputed company appeals • Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale • Maintain reputed company knowledge of NCQA and State regulations • Coordinate Fair Hearings with various internal departments and agencies • Performs other duties as assigned • Complies with reputed company policies and standards Applicants must reputed company in LA and have RN licensure Education/Experience: RN with 4+ years of clinical nursing and/or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Managed care or utilization review experience preferred. License/Certification: LPN, LVN, or RN license. Corporate & Louisiana reputed company Connections Requirements: reputed company state RN, LPN, or LVN, LPC, LCSW, or Psy.D license. Pay reputed company: $33.71 - $60.67 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company Apply tot his job Apply To this Job