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 and records
• Apply appropriate criteria for contracted and non-contracted cases and resolve escalated complaints
• Provide training and mentorship for less experienced appeals nurses and prepare cases for hearings

Required Qualifications

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