Texas Licensed Clinical Appeals Coordinator

Acting as the liaison for statewide appeals, the full-time Texas Licensed Clinical Appeals Coordinator will ensure compliance with State and NCQA requirements while reviewing clinical information, preparing response letters, and coordinating with Medical Directors in a remote environment. Key responsibilities Review clinical information for appeals to determine medical necessity using nationally recognized criteria Prepare response letters for member and provider clinical appeals, ensuring compliance with State and NCQA standards Coordinate Fair Hearings and maintain files and logs for all appeals Required qualifications 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 Current state RN, LPN, or LVN license Managed care or utilization review experience preferred Master's degree in a specialty therapy area or equivalent experience, with 3+ years providing therapy services in healthcare or home health settings Current state license in Physical Therapy, Occupational Therapy, or Speech-Language Therapy, if applicable