State Licensed Clinical Appeals Nurse

Job Summary

To support healthcare providers and patients, the remote Contract Clinical Appeals Nurse will evaluate appeals and disputes by analyzing medical records and documentation, making evidence-based decisions, and ensuring compliance with legal and clinical standards.

Key responsibilities

• Analyze medical records and case files to create objective summaries for appeal resolutions
• Exercise independent judgment to make decisions aligned with regulations and clinical standards
• Conduct thorough research using online resources to support well-informed decision-making

Required qualifications

• Associate's degree or higher in a healthcare-related field from an accredited institution
• LPN or RN License
• Minimum of three years' experience in medical appeals, dispute resolution, or clinical review
• Background in Nursing, Physical Therapy, Occupational Therapy, or Respiratory Therapy
• Proven ability to compose or assess appeals and payment-related determinations