Florida Licensed RN Clinical Appeals Nurse

Job Summary

A company is looking for an RN Clinical Appeals Nurse Remote.

Key Responsibilities

• Conducts clinical reviews of denied cases and reevaluates medical claims and records
• Applies clinical guidelines and criteria to assess service appropriateness and resolves escalated complaints
• Prepares and presents cases for administrative hearings and serves as a clinical resource for various stakeholders

Required Qualifications

• At least 3 years of clinical nursing experience, including 1 year in managed care
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-9, CPT coding, and HCPC
• Familiarity with CMS guidelines and applicable state regulatory requirements
• Experience in claims auditing, QA, or recovery auditing is preferred