Ohio Licensed Clinical Appeals Nurse

Job Summary

A company is looking for an RN Clinical Appeals Nurse Remote.

Key Responsibilities

• Conducts clinical reviews of denied cases and reevaluates medical claims according to applicable guidelines
• Identifies quality of care issues and resolves escalated complaints related to utilization management
• Serves as a clinical resource and provides training to less experienced team members

Required Qualifications

• At least 3 years of clinical nursing experience, with 1 year in managed care
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-9, CPT coding, and HCPC
• Familiarity with CMS guidelines and other relevant clinical guidelines
• Experience in claims auditing or recovery auditing is preferred