Florida Licensed Clinical Review Clinician
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Job Summary
To support the Medicare Appeals department, the remote Florida Licensed Clinical Review Clinician will perform clinical reviews to resolve appeals, prepare case reviews for Medical Directors, and communicate with stakeholders regarding appeal requests, working Monday through Friday with a weekend rotation.
Key responsibilities
- Perform clinical reviews of medical records and clinical data to determine medical necessity for appeals
- Prepare and analyze case reviews for Medical Directors, ensuring compliance with applicable criteria
- Communicate effectively with members, providers, and internal departments about appeal requests and resolutions
Required qualifications
- Valid and active RN or LPN license required; LVN preferred
- Associate or Bachelor's degree in Nursing, or higher preferred
- 2-4 years of related experience in Utilization Management or Appeals
- Medicare knowledge and experience with InterQual or Milliman required
- Graduate of an accredited school of nursing required
Complete Job Description
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