[Hiring] Clinical Appeals Coordinator @Independence Blue Cross

Role Description

The Clinical Appeals Coordinator, RN is responsible for supporting the end-to-end processing of clinical appeals, including:

• Medical necessity
• Benefit
• Pharmacy
• Behavioral health
• Administrative appeal issues

This role applies clinical nursing judgment, utilization management knowledge, benefit interpretation, medical policy, and evidence-based review criteria to ensure appeals are reviewed accurately, thoroughly, and within applicable regulatory, accreditation, and contractual timeframes.

The Clinical Appeals Coordinator serves as a clinical resource to:

• Appeals Specialists
• Team Leads
• Supervisors
• Medical Directors
• Peer reviewers
• Cross-functional partners

The role supports case development, documentation review, matched-specialty coordination, member and provider outreach, appeal correspondence, committee preparation, and audit-ready file completion.

Qualifications

• Active, unrestricted Registered Nurse license required; Pennsylvania RN license required or preferred based on business need.
• Minimum of five years of clinical nursing experience or equivalent healthcare experience required.
• Experience in utilization management, prior authorization, concurrent review, retrospective review, case management, clinical appeals, grievance and appeals operations, or related managed care operations required or strongly preferred.
• Demonstrated knowledge of clinical appeal processing, medical necessity review, benefit interpretation, medical policy application, and appeal documentation requirements.
• Knowledge of NCQA standards, state and federal appeal regulations, ERISA, ACA, and other regulatory or accreditation requirements applicable to appeal processing.
• Ability to review medical records, clinical documentation, denial rationale, benefit language, medical policy, and utilization management criteria to support accurate appeal handling.
• Strong understanding of health plan operations, including HMO, PPO, self-funded, fully insured, commercial, government program, or delegated vendor processes, as applicable.
• Excellent written and verbal communication skills, including the ability to prepare clear, accurate, member- and provider-facing correspondence.
• Strong analytical, critical-thinking, problem-solving, organizational, and time-management skills.
• Ability to work independently, manage competing priorities, meet regulatory deadlines, and escalate issues appropriately.
• High attention to detail and commitment to documentation quality, member advocacy, regulatory compliance, and audit readiness.
• Proficiency with Microsoft Office products, appeal systems, clinical documentation systems, claims systems, utilization management platforms, databases, and spreadsheet tools.

Requirements

• Bachelor of Science in Nursing required.
• Experience in a health plan, managed care organization, third-party administrator, utilization management organization, or delegated clinical review environment preferred.
• Experience with NCQA accreditation audits, state Department of Insurance audits, internal quality audits, client audits, or regulatory file reviews preferred.
• Familiarity with utilization review criteria such as InterQual, MCG, CMS guidance, evidence-based clinical guidelines, corporate medical policy, and plan-specific criteria preferred.
• Experience supporting external review, independent review organization cases, peer review coordination, expedited appeals, complex medical necessity appeals, pharmacy appeals, behavioral health appeals, or benefit appeals preferred.
• Knowledge of Medicare, Medicaid, Commercial, Exchange, ERISA, ACA, and state-specific appeal requirements preferred.
• Experience working with Medical Directors, physician consultants, independent reviewers, Compliance, Legal, Utilization Management, Care Management, Claims, Provider Relations, and Quality teams preferred.
• Experience identifying appeal trends, documentation gaps, overturn drivers, quality issues, or process improvement opportunities preferred.

Key Competencies

• Clinical judgment and utilization management expertise
• Appeal and grievance regulatory knowledge
• NCQA and audit-readiness mindset
• Medical necessity and benefit interpretation
• Evidence-based criteria application
• Strong written communication and documentation quality
• Member and provider advocacy
• Cross-functional collaboration
• Critical thinking and issue escalation
• Organization, prioritization, and deadline management
• Process improvement and quality focus

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.