Clinical Appeals Coordinator (Healthcare)

Location: Remote in Wisconsin; current Wisconsin licensure required

Salary: $33.71–$60.67 per hour

Company

hirify.global provides healthcare services and works to improve access to care for individuals, families, and communities.

What you will do

• Coordinate statewide appeals, fair hearings, external reviews, and related appeal activities.
• Review clinical information using nationally recognized criteria to determine medical necessity.
• Prepare reviews for cases that do not meet applicable criteria.
• Gather, analyze, and report information related to member and provider clinical appeals.
• Prepare response letters that comply with state and NCQA standards.
• Maintain appeal files and logs and coordinate with medical directors and internal departments.

Requirements

• Current Wisconsin professional license required.
• 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.
• Relevant licensure may include RN, LPN, LVN, LPC, LCSW, Psy.D., physical therapy, occupational therapy, or speech-language therapy, depending on the assigned program.
• Managed care, utilization review, healthcare operations, appeals, grievances, or case management experience is preferred.
• Specialty therapy roles require a relevant master's degree or equivalent experience and 3+ years of therapy services experience.

Culture & Benefits

• Full-time employment with a flexible approach to remote, hybrid, field, or office schedules.
• Health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off, and holidays.
• Pay is adjusted based on skills, experience, education, and other job-related factors.