Clinical Coordinator

Avanciers Incorporated is hiring a Clinical Coordinator for one of our clients.

Role: Clinical Coordinator

Location: Florida / Remote (as applicable)

Experience: 1-5 years of clinical nursing experience

Required License: Active, unrestricted Florida RN License or Compact RN License

Job Description:

• 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.

Qualifications:

• 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

Good to Have Experience

Managed Medicaid/Medicare Advantage experience; prior health plan UM/UR background; experience with appeal turnaround SLAs