Clinical Appeals RN - CA Licensed

Job Summary

Working remotely within the Eastern or Central Standard Time zones, the Clinical Appeals RN - CA Licensed will perform initial assessments of appeals and medical records, determine coverage criteria, and adapt to various appeal types while utilizing clinical judgment and critical thinking skills.

Key responsibilities

• Conduct initial assessment reviews of appeals and medical records to ensure compliance with coverage criteria
• Identify and request additional information necessary for processing appeals
• Utilize clinical nursing judgment to make decisions on administrative nurse level cases while managing multiple tasks across various computer systems

Required qualifications

• Current, valid, and unrestricted RN licensure in the state of residence
• 2+ years of clinical experience in an acute care or outpatient setting
• 1+ years of experience in Utilization Review or Medicaid/Medicare appeals
• Proven understanding of billable services and claims in a managed care environment
• Access to high-speed internet and the ability to work 8-5 within EST or CST