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 to assess service appropriateness
• Applies clinical guidelines and criteria to various cases, collaborating with the chief medical officer on denial decisions
• Serves as a clinical resource and provides training and mentorship to less experienced team members

Required Qualifications

• At least 3 years of clinical nursing experience, including 1 year in managed care or relevant programs
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-9, CPT coding, and HCPCS
• Familiarity with CMS guidelines and applicable state regulatory requirements
• Experience in claims auditing or clinical validation is preferred