RN Clinical Appeals Nurse

Job Summary

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

Key Responsibilities

• Performs clinical reviews of denied cases and reevaluates medical claims
• Applies criteria to assess appropriateness of services and resolves escalated complaints
• Prepares and presents cases for administrative hearings and serves as a clinical resource

Required Qualifications

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