Registered Nurse Clinical Appeals

Job Summary

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

Key Responsibilities

• Perform clinical reviews of denied cases and reevaluate medical claims
• Resolve escalated complaints regarding utilization management and quality of care issues
• Provide training and mentorship to less experienced appeals nurses and administrative 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 coding
• Familiarity with CMS guidelines and applicable state regulatory requirements
• Experience in claims auditing or clinical validation is preferred