Why this role stands out
Advance your career in healthcare with this Clinical Coordinator role, offering a hybrid work mode for flexibility and the chance to develop critical analytical skills. You'll thrive here if you have clinical nursing experience and are adept at navigating complex medical reviews and regulatory requirements. Apply today to contribute to important healthcare decisions and grow within a reputable organization.
Quick overview
Job description
Avanciers Incorporated is hiring a Clinical Coordinator for one of our clients.
- Reviews and investigates member and provider appeals involving clinical/medical necessity denials.
- Analyzes medical records, claims history, and clinical documentation against InterQual/MCG criteria to determine appeal outcomes.
- Ensures timely resolution in accordance with CMS, NCQA, Medicare, Medicaid, and state regulatory requirements.
- Documents clinical rationale and coordinates with Medical Directors on complex cases.
- Active, unrestricted Florida RN License or Compact RN License
- 1–5 years of clinical nursing experience
- 1–2 years of experience in Utilization Review, Case Management, or Appeals/Grievances within a managed care/health plan setting
- Strong knowledge of medical terminology and ICD-10/CPT coding basics
- Experience with medical necessity review and InterQual/MCG criteria
- Knowledge of CMS, NCQA, Medicare/Medicaid regulatory requirements
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