Clinical Appeals Nurse - State Licensed
Job Summary
A company is looking for a Clinical Appeals Nurse (RN) to make clinical decisions for appeals outcomes within compliance standards.
Key Responsibilities
- Perform clinical reviews of denied cases and assess service appropriateness
- Resolve escalated complaints and identify quality of care issues
- Prepare and present cases for administrative hearings and serve as a clinical resource
Required Qualifications
- Graduate from an Accredited School of Nursing; Bachelor's degree preferred
- 3-5 years clinical nursing experience, with 1-3 years in Managed Care
- Knowledge of ICD-9, CPT coding, and HCPC
- Active, unrestricted State Registered Nursing (RN) license in good standing
- Experience with CMS Guidelines, MCG, InterQual, and state regulatory requirements
COMPLETE JOB DESCRIPTION
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