RN Clinical Appeals Nurse

Job Summary

A company is looking for a Clinical Appeals Nurse, responsible for investigating and evaluating member and provider disputes regarding adverse determinations and coverage decisions.

Key Responsibilities:

• Investigate and evaluate written appeals and reconsideration requests from various stakeholders
• Respond with clinically informed and regulatory-compliant decisions through detailed correspondence
• Compile clinical records and communicate appeal outcomes to members and providers in a timely manner

Qualifications:

• High School Diploma or equivalent required; BSN or MSN strongly preferred
• Minimum 2 years of direct clinical experience in a medical-surgical or acute care setting, or 3 years in mental health settings
• Preferred experience includes at least 2 years in Utilization Management, Case Management, or Medical Review
• Required RN - Registered Nurse, State Licensure and/or Compact State Licensure
• Preferred certifications include CCM - Certified Case Manager and LNCC - Legal Nurse Consultant Certified