California Licensed Clinical Appeals Nurse

Job Summary

Reviewing and processing appeals for inpatient and outpatient services, the full-time California Licensed Clinical Appeals Nurse will collaborate with medical directors and providers to ensure timely and accurate appeal determinations in a fully remote environment.

Key responsibilities

• Reviews appeal requests for medical necessity and refers cases requiring MD approval
• Applies evidence-based clinical criteria to conduct objective medical necessity reviews and make recommendations
• Coordinates peer-to-peer conversations with providers and maintains documentation of all appeal decisions

Required qualifications

• Current, active, and unrestricted California LVN or RN license
• Minimum of 2 years' clinical nursing experience in med/surg, case management, or acute care
• At least 1 year of experience in utilization management or appeals/denials within a managed care environment
• Completion of an accredited LVN or RN nursing program
• Knowledge of ICD-10, CPT codes, and managed care plans