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 while adhering to corporate policies and regulations
• Organizes appeal cases for physician review by compiling necessary information and communicates final decisions to members and providers
• Utilizes nursing expertise to prioritize and assess appeal requests, ensuring compliance with regulatory requirements and collaborating with physician specialists

Required Qualifications

• High School Diploma or GED
• Registered Nurse (RN) State Licensure required upon hire
• 2 years of medical-surgical or similar clinical experience, or 3 years in a mental health setting
• Certified Case Manager (CCM) and/or Legal Nurse Consultant Certified (LNCC) preferred upon hire
• Experience in Medical Review, Utilization Management, or Case Management is preferred