Remote Appeals Specialist - RN, LPN

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist, 100% Remote.

Key Responsibilities

• Manage clinical case development and resolution, ensuring compliance with regulations
• Prepare cases for Medical Director Review and external appeal processes
• Handle all Department of Health and executive complaints as needed

Required Qualifications

• Valid RN, LPN, or Dental Hygienist license
• Bachelor's degree preferred
• Experience in clinical practice and appeals & grievances or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Ability to manage large caseloads in a fast-paced environment