RN Clinical Appeals Specialist

Job Summary

A company is looking for a Clinical Appeals RN - Commercial LOB - Remote.

Key Responsibilities

• Conducts reviews of member and provider appeals
• Analyzes claim adjustment and claim history
• Reviews denied services according to policies, regulations, and clinical criteria

Required Qualifications

• Active, unrestricted RN license in state of residence
• 5+ years of clinical experience as an RN in an acute, inpatient hospital setting
• Experience in Utilization Management, pre-authorization, concurrent review, or appeals
• Solid computer skills including proficiency in Microsoft Office applications
• Ability to work on Saturdays in a flexible schedule