RN Clinical Appeals Specialist

Job Summary

A company is looking for a Clinical Appeals RN - Commercial Plan (M-F)- Remote.

Key Responsibilities

• Conduct reviews of member and provider appeals
• Analyze claim adjustments and histories, and review previous decisions
• Evaluate denied services in accordance with policies, benefit plans, and clinical criteria, rendering approvals when appropriate

Required Qualifications

• Active, unrestricted RN license in state of residence
• 5+ years of clinical experience as an RN, including in an acute, inpatient hospital setting
• Experience applying benefits and criteria to clinical review
• Utilization Management, pre-authorization, concurrent review, or appeals experience
• Solid computer skills including proficiency in Microsoft Office and ability to access multiple computer platforms