Registered Nurse - Appeals

Job Summary

A company is looking for a Clinical Review Clinician - Appeals RN.

Key Responsibilities

• Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data for medical necessity
• Prepares case reviews for Medical Directors and ensures timely processing of appeals in compliance with relevant standards
• Communicates with members, providers, and other departments regarding appeals requests and generates resolution communications

Required Qualifications, Training, and Education

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience preferred
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• Knowledge of utilization management processes preferred
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required