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 appeals related to adverse coverage decisions, ensuring compliance with state and federal regulations while communicating outcomes to members and providers.

Key responsibilities

• Investigates and analyzes written appeals from various sources, responding with detailed letters that uphold corporate policies
• Organizes appeal cases for physician review, compiling necessary clinical and contractual information, and communicates final decisions to stakeholders
• Utilizes nursing expertise to prioritize appeal requests and collaborates with Independent Review Organizations for clinical opinions on adverse decisions

Required qualifications

• Bachelor's Degree in Nursing or 4 years of relevant work experience in lieu of a degree
• Active RN - Registered Nurse state licensure or compact state licensure upon hire
• 3 years of clinically related experience in Medical Review, Utilization Management, or direct patient care
• CCM - Certified Case Manager or LNCC - Legal Nurse Consultant certifications preferred upon hire
• Direct experience with Appeals and Grievances in a healthcare payor organization is preferred