Florida Licensed Appeals Nurse

Job Summary

A company is looking for an Appeals Nurse to facilitate medical necessity appeals and denials.

Key Responsibilities

• Review clinical data to determine claim payment based on company policies and NCQA guidelines
• Prepare case reviews for the Medical Director and generate appeal resolution communications
• Maintain the appeals process within NCQA timeframes and assist with policy revisions

Required Qualifications

• LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience
• Proficient with Microsoft Office applications
• Experience with utilization or appeals review preferred
• Knowledge of InterQual criteria preferred
• Current RN or LPN license