Clinical Appeals Coordinator - (Orlando, FL)

HourlyPosition Purpose: 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 qualifications. Review clinical details 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 details regarding member and provider clinical appeals, including details 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 all appeals Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale Maintain working knowledge of NCQA and State regulations Coordinate Fair Hearings with various internal departments and agencies