Maine Licensed Appeals Nurse

Job Summary

A company is looking for a Utilization Review and Appeals Nurse - Remote.

Key Responsibilities

• Review and resolve clinical appeals and disputes
• Interpret clinical documentation and ensure compliance with regulatory standards
• Coordinate clinical resolutions and participate in quality improvement initiatives

Required Qualifications

• Associate Degree in Nursing (ADN); Bachelor's degree preferred
• Active, unrestricted Compact Registered Nurse (RN) license
• 3+ years of RN clinical experience, preferably in a hospital setting
• Thorough understanding of CMS Medicare Advantage regulations and NCQA guidelines
• Experience in utilization management and managing appeals or disputes