Pennsylvania Licensed RN Clinical Appeals Specialist

Job Summary

Managing clinical appeals from intake through resolution, the full-time contract RN Clinical Appeals Specialist will review documentation, apply clinical nursing knowledge, and coordinate matched-specialty reviews while working remotely in Philadelphia, PA.

Key responsibilities

• Manage assigned clinical appeals, ensuring all documentation is complete and accurate
• Apply clinical nursing knowledge and utilization management principles to support case classification and appeal handling
• Coordinate and document matched-specialty reviews and prepare clear written correspondence to stakeholders

Required qualifications

• Bachelor of Science in Nursing required
• Active, unrestricted Pennsylvania RN license required
• Minimum of five years of clinical nursing experience or equivalent healthcare experience
• Experience in utilization management, clinical appeals, or related managed care operations
• Knowledge of NCQA standards and state and federal appeal regulations