North Carolina Licensed Clinical Appeal Nurse

Job Summary

A company is looking for a Clinical Appeal Nurse.

Key Responsibilities

• Review and analyze pre and post service medical necessity and benefit appeals, and quality of care grievances
• Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs)
• Ensure adherence to Appeals and Utilization Management processes and regulatory requirements

Required Qualifications

• Active and unrestricted RN or LPN license
• Minimum of 5 years' experience in Clinical Appeals and Grievances within a managed care or payor setting
• Minimum of 5 years' clinical experience across various care settings
• Strong understanding of UM/Appeals regulatory guidelines
• Proficiency in Clinical Appeals, Utilization Review, and Grievance processes