[Hiring] Clinical Appeals Intake and Review Coordinator @The Phia Group

Role Description

The Clinical Appeals Intake & Review Coordinator supports the appeals team by providing clinical expertise during the intake, triage, and preparation of complex health benefit appeals. This role serves as a clinical resource to help ensure appeals involving medical necessity, experimental/investigational treatment, complex medical records, or other clinical issues are identified and organized early in the process. The position works closely with appeal consultants, legal resources, Provider Relations, claims partners, and independent clinical reviewers. The role does not make final benefit determinations or replace independent clinical review. Its purpose is to ensure the quality and efficiency of the appeal process by ensuring clinically complex matters are appropriately developed before directive and independent review.

• Support a culture that is consistent with The Phia Group's core values;
• Apply up-to-date documentation/guidelines when triaging appeals;
• Perform clinical intake and triage of complex appeals;
• Review appeal submissions and medical records to identify:
  • Diagnoses and relevant medical history;
  • Treatments and services at issue;
  • Medical necessity or experimental/investigational questions;
  • Key clinical arguments and relevant dates;
• Identify missing or incomplete clinical documentation and coordinate requests for additional records, policies, prior reviews, or utilization management materials;
• Prepare concise, objective clinical summaries and chronologies for appeal reviewers;
• Help determine when an appeal requires an independent clinical review and identify the appropriate clinical specialty;
• Prepare and organize materials for submission to independent clinical reviewers/IROs;
• Monitor clinical review activity and proactively identify issues that could create appeal deadline risk;
• Assist appeal team members in understanding complex medical terminology, treatment pathways, and clinical documentation;
• Collaborate with PGC, claims, and other internal teams when appeals identify broader provider or operational issues;
• Support continuous improvement of appeal clinical intake, documentation, and appeal workflows;
• Assist department in customizing and/or creating appeal directives as needed;
• Work closely with The Phia Group’s PGC team to perform any applicable research as it relates to claims and appeals, as well as research nationally recognized sources and information to ensure support of products and solutions;
• Identify any tools and/or technologies required to expand products/solutions;
• Assist in tracking and monitoring productivity and value with existing and future concepts;
• Perform other tasks and related responsibilities as well as work on special projects as assigned.

Qualifications

• LPN or RN required;
• Bachelor of Science in Nursing (BSN) preferred;
• Appeals experience preferred;
• Strong clinical background with experience reviewing and synthesizing medical records;
• Ability to identify relevant clinical issues within large or complex medical files;
• Strong written communication skills, including the ability to create clear, neutral clinical summaries;
• Strong organizational skills and ability to manage multiple matters with regulatory or contractual deadlines;
• Ability to work effectively across clinical, legal, operational, and client-facing teams;
• Experience with and working knowledge of health insurance, Medicare guidelines and various healthcare programs;
• Exceptionally professional written communication skills;
• Highly organized with attention to detail and the ability to multi-task.

Company Description

The Phia Group, LLC is a thriving, service-oriented company headquartered in Canton, Massachusetts. As consultants, we represent health plans nationwide, providing our clients with innovative cost-containment solutions through our unique service offerings. As a result of our most valuable resource, our talented and committed team, we continue to enjoy high levels of growth.

At The Phia Group, whose mission is to provide high quality yet affordable healthcare to American employees and their families, you can look forward to not only exceptional benefits for yourself but also being immersed in a company that was named one of USA Today’s Top Workplaces for 2026. Meanwhile, from a regional perspective, The Boston Globe, Courier Journal, and Louisville Business First annually recognize our unwavering commitment to upholding an internal culture of inclusivity, enjoyment, and empathy for our valued employees by listing The Phia Group in their respective lists for the Top Places to Work.