Clinical Appeals Coordinator, RN - Peak Health

📋 Description

• • Shape the future of healthcare delivery by joining Peak Health as our Clinical Appeals Coordinator, RN—an opportunity to build a health plan from the ground up while working 100 % remotely from Monongalia County, WV. You will report directly to the Health Plan Manager of Utilization Review and serve as a pivotal member of the medical management team, ensuring every member and provider receives fair, evidence-based resolution of medical necessity appeals.
• • Own the full lifecycle of appeals and grievances: conduct thorough investigations, review complex medical records, and synthesize clinical data into concise, defensible summaries for the medical director and interdisciplinary care team. Your clinical judgment will directly influence coverage decisions, member experience, and provider satisfaction.
• • Drive compliance excellence by monitoring and meeting stringent appeal timeframes that align with enterprise policies, state mandates, and federal regulations (including CMS and NCQA standards). You will maintain meticulous documentation in the case management system and generate clear, compassionate written responses to members and providers.
• • Act as the resident subject-matter expert on appeals and grievances, serving as a go-to resource for colleagues across Utilization Review, Case Management, and Quality. You will distill evolving regulatory guidance into actionable workflows, mentor junior staff, and champion continuous process improvement.
• • Leverage nationally recognized criteria—InterQual and/or Milliman Care Guidelines—to conduct prospective, concurrent, and retrospective reviews of denied services. Your analyses will balance fiscal stewardship with optimal patient outcomes, ensuring every decision is clinically sound and transparent.
• • Collaborate in real time with physicians, coders, and data analysts to identify trends in denial reasons, length-of-stay outliers, and readmission patterns. Your insights will feed directly into population health initiatives, network contracting strategies, and member education programs.
• • Embrace a culture of lifelong learning by participating in weekly case conferences, regulatory webinars, and Lean improvement events. You will pilot new technologies, refine appeal letter templates, and track KPI dashboards that showcase your impact on turnaround times and overturn rates.
• • Enjoy the flexibility of a fully remote, 40-hour workweek with no on-call obligations. You will receive a secure laptop, dual monitors, and VPN access, allowing you to create an ergonomic home office while staying seamlessly connected to your team through Microsoft Teams and Epic.
• • Contribute to Peak Health’s mission of reimagining rural healthcare access. Every appeal you resolve strengthens trust between members and providers, reduces administrative burden, and ultimately improves health outcomes across West Virginia and surrounding regions.