State Licensed Clinical Appeals Nurse

Job Summary

To support the medical management team, the full-time State Licensed Clinical Appeals Nurse will investigate and process medical necessity requests from members and providers while working remotely.

Key responsibilities

• Conducts investigations and reviews for member and provider medical necessity appeals
• Reviews medical records of denied services and provides summaries to the medical director and care team
• Ensures compliance with appeal timeframes and documentation standards

Required qualifications

• Current Registered Nurse or Licensed Practical Nurse license issued by the state or multi-state license through the enhanced Nurse Licensure Compact (eNLC)
• Three years of clinical claims processing and review experience
• Three years of experience working with appeals and grievances
• Two years of customer service experience
• Bachelor of Science in Nursing is preferred