RN Clinical Appeals Nurse

Job Summary

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

Key Responsibilities

• Perform clinical reviews of denied cases and reevaluate medical claims based on regulatory requirements and clinical guidelines
• Resolve escalated complaints and identify quality of care issues while serving as a clinical resource for various stakeholders
• Prepare and present cases for administrative hearings and provide training and mentoring 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, Medicaid, Medicare, and applicable state regulatory requirements
• Experience in critical thinking and effective interaction with clinical leaders and peers