Maryland Licensed Clinical Appeals Nurse

Job Summary

Working remotely with occasional in-office meetings, the full-time Maryland Licensed Clinical Appeals Nurse will investigate and analyze member and provider disputes regarding adverse coverage decisions, utilizing clinical expertise to formulate responses while adhering to state and federal regulations.

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 by compiling relevant clinical and claims information, preparing written cases, and communicating final decisions to members and providers
• Collaborates with Independent Review Organizations and contracted physicians to assess the appropriateness of adverse decisions, while maintaining knowledge of current medical practices and procedures

Required qualifications

• Bachelor of Science in Nursing or related discipline, or four years of relevant clinical nursing experience in lieu of a degree
• Active RN - Registered Nurse state licensure or compact state licensure
• Three years of clinically related experience in Medical Review, Utilization Management, or health insurance payer roles
• Knowledge of medical terminology and understanding of regulatory and accreditation requirements
• Experience in a healthcare payer organization is preferred