Maryland Licensed Clinical Appeals Nurse

Job Summary

A company is looking for a Clinical Appeals Nurse (Remote).

Key Responsibilities

• Investigates and analyzes written appeals and reconsideration requests from various sources, responding with detailed letters that comply with corporate policies and regulations
• Organizes appeal cases for physician review, compiling necessary information and communicating final decisions to members and providers
• Utilizes nursing expertise to assess appeal requests, collaborating with Independent Review Organizations and responding to regulatory complaints

Required Qualifications

• High School Diploma or GED
• RN - Registered Nurse - State Licensure and/or Compact State Licensure upon hire required
• 2 years of medical-surgical or similar clinical experience OR 3 years in a mental health or psychiatric setting
• CCM - Certified Case Manager and LNCC - Legal Nurse Consultant Certified preferred upon hire
• Preferred: 2 years experience in Medical Review, Utilization Management, or Case Management in a healthcare payor organization