Clinical Review Clinician - Appeals

Job Summary

A company is looking for a Clinical Review Clinician - Appeals.

Key Responsibilities:

• Prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing appeal basis
• Ensure timely review, processing, and response to appeals in accordance with standards
• Communicate with members, providers, and other departments regarding appeals requests

Required Qualifications:

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing with 2-4 years of related experience
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• State Licensure as LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist required