Maryland Licensed Appeals Nurse

Job Summary

Responsible for managing medical appeals, the full-time Maryland Licensed Appeals Nurse will facilitate and resolve member and practitioner appeals remotely while ensuring compliance with regulatory and accreditation standards.

Key responsibilities

• Conducts initial medical record reviews for clinical appeals and prepares summaries for Medical Director's review
• Documents all appeals accurately and timely in the clinical software system, maintaining secure and comprehensive files
• Collaborates with Medical Directors on handling denials and participates in multidisciplinary quality improvement teams

Required qualifications

• Bachelor's degree in Nursing required
• 5-7 years of diverse clinical experience with knowledge of authorization processes
• 1-2 years of recent utilization review experience required
• Active and unrestricted Nursing License in Maryland or the District of Columbia
• No prior or current Medicare or Medicaid sanctions required