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 related to utilization management and identify quality of care issues
• Provide training and mentorship to less experienced appeals nurses and serve as a clinical resource within the organization

Required Qualifications

• At least 3 years of clinical nursing experience, including 1 year in managed care or relevant program experience
• 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 state regulatory requirements
• Critical-thinking skills and ability to interact effectively with clinical leaders