Medicare Appeals Clinician

Job Summary

A company is looking for a Clinical Review Clinician_Appeals.

Key Responsibilities

• Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data
• Prepares case reviews for Medical Directors and ensures timely responses to appeals in compliance with standards
• Communicates with members and providers regarding appeals, and collaborates with teams to improve processes

Required Qualifications, Training, and Education

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience, preferably with Medicare Appeals experience
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• State Licensure required for LPN, LVN, or RN; other relevant licenses may also be accepted
• Knowledge of utilization management processes preferred