Clinical Coordinator

Job Title: Clinical Coordinator
 Reports To: Sr. Director of Operations
 FLSA Status: Full-Time, Non-exempt

Role Summary
The Clinical Coordinator is responsible for reviewing and interpreting clinical documentation to support medical necessity determinations for Non-Emergency Medical Transportation (NEMT) services. This role ensures that all transportation requests—both in-state and out-of-state—are clinically appropriate, cost-effective, and compliant with regulatory and contractual requirements. The Clinical Coordinator serves as a key liaison between healthcare providers, case managers, and internal operations teams, ensuring that all eligibility decisions are well-supported, documented, and communicated effectively.

Key Responsibilities

Clinical Review & Eligibility Determination
 • Review clinician documentation, medical records, and case notes to determine medical necessity for transportation services
 • Evaluate and approve or deny trip requests based on established clinical guidelines and contract requirements
 • Assess both in-state and out-of-state transportation requests to ensure appropriate level of service
 • Determine the least costly, medically appropriate transportation mode based on member needs
 • Monitor utilization trends of NEMT services within the assigned service area
 • Identify patterns of over- or under-utilization and escalate concerns as appropriate
 • Collaborate with internal teams to ensure efficient and appropriate use of transportation resources

Stakeholder Communication
 • Communicate determinations (approvals/denials) clearly and timely to case managers, treatment facilities, and relevant stakeholders
 • Provide clinical justification for all decisions, including participation in case discussions when required
 • Serve as a subject matter expert on medical necessity for internal teams and external partners
 • Participate in case management meetings with the Department, providers, and other stakeholders as needed
 • Present and defend clinical determinations with supporting documentation and rationale
 • Collaborate with case managers and healthcare professionals to clarify documentation or request additional information

Compliance & Documentation
 • Ensure all activities comply with HIPAA and applicable state and federal regulations
 • Maintain accurate, complete, and auditable records of all clinical reviews and determinations
 • Ensure denial notices are accurate, compliant, and issued within required timeframes

Operational Coordination
 • Coordinate with internal teams, including Financial Management and Operations, on pre- and post-trip documentation requirements
 • Support the administration of statewide NEMT requests, including complex and non-traditional transport cases
 • Assist in outreach and education efforts to explain NEMT services and eligibility criteria to stakeholders

Qualifications

• Demonstrated experience reviewing clinical documentation and making medical necessity determinations
 • Strong knowledge of medical terminology, diagnoses, and clinical documentation interpretation
 • Experience in healthcare, case management, utilization review, or a related field preferred
 • Ability to assess transportation needs based on clinical conditions and functional limitations
 • Excellent communication skills with the ability to interact with healthcare professionals and non-clinical stakeholders
 • Strong analytical and decision-making skills with attention to detail
 • Knowledge of Medicaid or managed care environments preferred
 • Proficiency in Microsoft Office and healthcare management systems
 • Must be able to participate in meetings, including virtual and in-person case reviews, as required