Clinical Claims Appeals Specialist - WV

Job Summary

A company is looking for a Clinical Claims Appeals Specialist.

Key Responsibilities:

• Evaluate and analyze claim appeals to determine validity and appropriateness
• Communicate with policyholders and healthcare providers to gather information and clarify claim details
• Maintain accurate records of appeal cases, prepare reports, and identify process improvement opportunities

Required Qualifications:

• Current unencumbered licensure as a registered professional nurse or practical nurse with relevant clinical experience
• Three years of experience in clinical claims processing and review, including appeals and grievances
• Bachelor's degree in healthcare, coding, or nursing discipline OR eight years of relevant claims experience in a clinical or insurance setting
• Minimum five years of operational managed care experience
• Proficiency in Medicare/Medicaid guidelines and regulatory requirements