RN Clinical Specialist

Job Summary

Managing clinical case development and resolution, the full-time RN Clinical Specialist will work remotely to handle member and provider complaints, ensuring compliance with regulations while managing a caseload of appeals and grievances from Wednesday to Saturday.

Key responsibilities

• Oversee case development and resolution for clinical cases, including medical necessity and prior approval
• Prepare cases for Medical Director Review and external appeals, ensuring all pertinent information is included
• Manage and document all cases within regulatory timeframes, communicating effectively with colleagues

Required qualifications

• Current RN or LPN license
• Experience in clinical practice, particularly in appeals & grievances or utilization management
• Understanding of Utilization Review Guidelines and relevant regulations
• Proficiency in Microsoft Word, Excel, and care management systems
• Ability to manage a large caseload in a fast-paced environment