Maine Licensed Clinical Appeals Professional

Job Summary

A company is looking for a Clinical Appeals Professional (Remote within Maine).

Key Responsibilities

• Review and interpret medical records to assess clinical appropriateness and medical necessity
• Coordinate and manage appeal cases throughout the review lifecycle, including hearings representation
• Conduct outreach to healthcare providers to obtain necessary medical records and support clinical discussions

Required Qualifications

• Active, unrestricted RN, Social Worker, or applicable clinical license in good standing
• Bachelor's degree in Nursing, Social Work, Social Services, or a related field
• Experience in utilization management, clinical appeals, case management, or care coordination
• Ability to present and defend clinical cases during consultations and hearings
• Understanding of clinical best practices and evidence-based standards in alignment with regulations