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
• Applies medical guidelines and criteria to assess service appropriateness and care levels
• Serves as a clinical resource and provides training for appeals nurses and administrative staff

Required Qualifications

• At least 3 years of clinical nursing experience, including 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 state regulatory requirements
• Experience in utilization review, medical claims review, or related fields