Registered Nurse Appeals Clinician

Job Summary

Utilizing clinical expertise to resolve member and provider appeals, the full-time Registered Nurse Appeals Clinician will work remotely from Oregon, Washington, Idaho, or Utah, ensuring compliance with medical policies and conducting clinical appeal reviews.

Key responsibilities

• Applies nursing expertise to ensure appeal decisions comply with medical necessity guidelines and industry standards
• Conducts clinical appeal reviews in accordance with member benefits and provider contracts
• Consults with physician advisers for clinically appropriate determinations and educates non-clinical staff on clinical cases

Required qualifications

• Bachelor's Degree in Nursing with 3 years of clinical experience or equivalent combination of education and experience
• Active RN license in Oregon, Washington, Idaho, or Utah
• Experience in health insurance, coding/claims review, or case management
• Competency in claim review and familiarity with medical procedures and healthcare practices
• Knowledge of CPT, ICD-9, HCPCS coding, and Milliman Care Guidelines (MCG)