Rhode Island Licensed Clinical Appeals Specialist

Job Summary

A company is looking for a Clinical Appeals Specialist PD to manage appeals initiatives and collaborate with various departments.

Key Responsibilities

• Coordinate governmental and third-party appeals with physicians and medical directors
• Prepare and maintain documentation, ensuring accuracy and completeness of appeal data
• Conduct retrospective reviews and participate in committees to improve audit and appeal processes

Required Qualifications

• Licensure as a Registered Nurse in the State of Rhode Island or under the Nurse Licensure Compact
• Bachelor's Degree in Nursing, Health Science, or Health Business; Master's Degree preferred
• Three years of relevant clinical and/or administrative experience, with two years in utilization review
• Working knowledge of level of care criteria and state/federal regulations