RN Clinical Appeals Nurse

Job Summary

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

Key Responsibilities

• Conducts clinical reviews of denied cases and reevaluates medical claims and records
• Applies criteria to assess service appropriateness and resolves escalated complaints
• Provides training and mentorship to less experienced 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
• Knowledge of ICD-9, CPT coding, and HCPCS
• Familiarity with CMS guidelines and applicable state regulations
• Experience in claims auditing, QA, or recovery auditing is preferred