Pennsylvania Licensed Clinical Appeals Nurse

Job Summary

A company is looking for a Clinical Appeals Nurse.

Key Responsibilities

• Reviews payor denials and writes comprehensive appeal letters based on medical policy guidelines
• Coordinates appeals requiring physician input and manages claims that cannot be appealed further
• Monitors payor trends and ensures compliance with regulatory requirements

Required Qualifications

• Bachelor's Degree in Nursing or Specialized Diploma
• 10 years of clinical or case management/utilization review experience
• Knowledge of Interqual/medical policy criteria and hospital departmental procedures
• RN - Licensed Registered Nurse in Pennsylvania
• Intermediate Excel and MS Word experience