LPN or RN Clinical Specialist

Job Summary

To support the management of clinical appeals and grievances, the full-time Appeals & Grievances Clinical Specialist will receive, investigate, and respond to member and provider issues while working remotely across various states.

Key responsibilities

• Ensures proper classification and processing of appeals and grievances according to company policy
• Enters data into medical management services and collaborates with other departments for thorough investigations
• Prepares for and participates in regulatory site visits and performs additional assigned duties

Required qualifications

• LPN or RN license
• Experience in clinical practice with a focus on appeals & grievances or utilization management
• Understanding of Utilization Review Guidelines, InterQual, or Medicare Guidelines
• Proficiency in Microsoft Word, Excel, and corporate email systems
• Ability to manage large caseloads in a fast-paced environment