Wisconsin Licensed Clinical Appeals Coordinator

To support statewide appeals and ensure compliance with State and NCQA requirements, the full-time Wisconsin Licensed Clinical Appeals Coordinator will manage clinical information reviews, prepare compliant response letters, and coordinate Fair Hearings while working remotely. 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 regulations Coordinate with Medical Directors and maintain knowledge of NCQA and State regulations Required qualifications Current RN, LPN, or LVN license in Wisconsin 4+ years of clinical nursing or case management experience for RN or 5+ years for LPN/LVN Experience in managed care, utilization management, or healthcare operations preferred Ability to gather, analyze, and report clinical information effectively Familiarity with NCQA and State regulations related to clinical appeals