Clinical Appeals Coordinator, RN
Location: Fully remote; candidates MUST reside in Pennsylvania, New Jersey, or Delaware to be considered for this position
Licensure: Active, unencumbered Pennsylvania RN license or a multistate compact RN license that authorizes practice in Pennsylvania.
Schedule: Standard business hours during the week with rotating Saturday and holiday coverage required. Assigned Saturday and holiday shifts are 8:00 a.m.–1:00 p.m.
Position Overview
The Clinical Appeals Coordinator, RN supports the end-to-end processing of clinical appeals involving medical necessity, benefit coverage, pharmacy, behavioral health, and administrative issues. This position applies clinical nursing judgment, utilization management knowledge, benefit interpretation, medical policy, and evidence-based review criteria to ensure appeals are handled accurately, thoroughly, and within applicable regulatory, accreditation, and contractual deadlines.
The coordinator serves as a clinical resource to Appeals Specialists, department leadership, Medical Directors, physician reviewers, and cross-functional partners. Responsibilities include case development, medical-record review, member and provider outreach, specialty-review coordination, correspondence, committee preparation, and audit-ready documentation.
Key Responsibilities
Manage assigned clinical appeals from intake through resolution, including documentation collection, clinical research, outreach, review coordination, determination support, notifications, and implementation of appeal decisions.
Review appeal files for completeness and accuracy, including denial letters, medical records, benefit provisions, prior authorization history, claims information, medical policies, review criteria, and member or provider submissions.
Apply clinical nursing knowledge, utilization management principles, benefit language, and evidence-based criteria to support appropriate appeal classification and handling.
Identify medical necessity, benefit coverage, administrative, pharmacy, behavioral health, and regulatory issues; escalate complex or high-risk cases appropriately.
Assist Appeals Specialists in identifying the appropriate review level, reviewer qualifications, matched-specialty requirements, and questions for Medical Directors or independent physician consultants.
Coordinate and document matched-specialty reviews, peer reviews, Medical Director reviews, external review preparation, and committee activities.
Review investigations, case summaries, outreach records, clinical documentation, and system entries to ensure accuracy, completeness, and compliance with departmental standards.
Prepare and review clear, accurate, and timely correspondence for members, providers, authorized representatives, and other stakeholders.
Review Level 1 and Level 2 case summaries before committee meetings to ensure clinical issues, appeal rationale, benefit provisions, medical policies, and reviewer questions are clearly presented.
Monitor case status and appeal inventory to meet applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround-time requirements.
Maintain audit-ready files documenting the appeal, investigation, clinical and benefit review, applicable criteria, reviewer involvement, determination rationale, and required notifications.
Collaborate with Compliance, Medical Directors, Utilization Management, Care Management, Claims, Provider Relations, and other business areas to resolve appeal-related issues.
Support policy, procedure, workflow, system, regulatory, and accreditation changes affecting clinical appeals.
Identify recurring appeal issues, documentation gaps, and opportunities for process improvement, quality improvement, provider education, and utilization management feedback.
Participate in training, calibration, quality reviews, audit preparation, and continuous improvement activities while maintaining privacy and confidentiality requirements.
Required Qualifications
Active, unencumbered Pennsylvania RN license or a multistate compact RN license that authorizes practice in Pennsylvania.
Residence in Pennsylvania, New Jersey, or Delaware.
Bachelor of Science in Nursing.
Minimum of five years of clinical nursing experience.
Experience in utilization management, prior authorization, concurrent review, retrospective review, case management, clinical appeals, grievance and appeals operations, or related managed care operations.
Demonstrated knowledge of clinical appeal processing, medical necessity review, benefit interpretation, medical policy application, and appeal documentation requirements.
Knowledge of NCQA standards and applicable state and federal appeal requirements, including ERISA and ACA.
Ability to interpret medical records, clinical documentation, denial rationale, benefit language, medical policies, and utilization management criteria.
Strong understanding of health plan operations and applicable HMO, PPO, self-funded, fully insured, commercial, government-program, or delegated-vendor processes.
Excellent written and verbal communication skills, including the ability to prepare clear member- and provider-facing correspondence.
Strong analytical, critical-thinking, organizational, problem-solving, and time-management skills.
Ability to work independently, manage competing priorities, meet regulatory deadlines, and escalate concerns appropriately.
High attention to detail and commitment to documentation quality, member advocacy, compliance, and audit readiness.
Proficiency with Microsoft Office, spreadsheets, databases, and appeals, claims, clinical documentation, or utilization management systems.
Availability for rotating Saturday and holiday shifts from 8:00 a.m.–1:00 p.m.
Preferred Qualifications
Experience supporting NCQA accreditation audits, state Department of Insurance audits, internal quality audits, client audits, or regulatory file reviews.
Familiarity with InterQual, MCG, CMS guidance, evidence-based clinical guidelines, corporate medical policies, and plan-specific review criteria.
Experience with external reviews, independent review organizations, peer review coordination, expedited appeals, or complex medical necessity, pharmacy, behavioral health, and benefit appeals.
Knowledge of Medicare, Medicaid, Commercial, Exchange, and state-specific appeal requirements.
Experience collaborating with Medical Directors, physician consultants, independent reviewers, Compliance, Legal, Utilization Management, Care Management, Claims, Provider Relations, and Quality teams.
Experience identifying appeal trends, documentation gaps, overturn drivers, quality concerns, and process improvement opportunities.
Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.