Clinical Appeals RN

Job Summary

Working remotely in a full-time capacity, the Clinical Appeals RN will perform medical necessity reviews, consult with Medical Directors, and collaborate with various departments to ensure appropriate care and compliance with established criteria.

Key responsibilities

• Conducts inpatient, concurrent, and retrospective reviews to assess medical appropriateness and compliance with policies
• Documents clinical information accurately and timely while meeting production and quality metrics
• Identifies clinical program opportunities and refers members to appropriate healthcare programs

Required qualifications

• Bachelor's degree or four years of relevant work experience
• Current State Licensure as a registered nurse
• Three years of clinical experience
• Utilization Management experience
• Experience in the health plan industry