Appeals and Grievances Clinical Specialist - RN or LPN

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist - RN or LPN, 100% Remote.

Key Responsibilities

• Manage clinical case development and resolution for member and provider complaints
• Prepare cases for Medical Director Review and external appeals processes
• Ensure compliance with Federal and State regulations while managing caseloads

Required Qualifications

• Must be an RN, LPN, or Dental Hygienist
• Bachelor's degree preferred
• Experience in clinical practice, appeals & grievances, or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Ability to work with care management systems and multiple computer applications