State Licensed Appeals Nurse

Job Summary

A company is looking for an Appeals Nurse.

Key Responsibilities

• Examine medical records and claims for first-level appeal cases to assess medical necessity and compliance with Medicare guidelines
• Collaborate with Appeals Examiners and Reps to ensure timely medical reviews and redeterminations
• Utilize various systems, including the Medicare Appeal System and Hyland OnBase, for managing appeals

Required Qualifications

• Associate's Degree in Nursing (ASN) or Bachelor's Degree in Nursing (BSN)
• Active RN license in good standing for the applicable state
• 1 or more years of clinical experience in a healthcare setting
• Basic knowledge of medical/clinical review processes, such as Appeals and Utilization Review
• Solid computer skills with experience in MS Outlook, Teams, OneNote, Word, and Excel