New York RN Appeals Nurse

Job Summary

A company is looking for an Appeals Nurse to facilitate medical necessity appeals and denials.

Key Responsibilities

• Review clinical data to determine claim payments and manage appeal resolutions
• Prepare case reviews for the Medical Director and generate communication regarding appeal outcomes
• Maintain the appeals process within NCQA timeframes and assist in policy revisions as needed

Required Qualifications

• LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience
• Proficient with Microsoft Office applications
• Experience with utilization or appeals review preferred
• Knowledge of InterQual criteria preferred
• RN or LPN license required