State Licensed Clinical Appeals Nurse

Job Summary

Reviewing medical records and preparing clinical appeals for medical necessity denials, the full-time State Licensed Clinical Appeals Nurse will utilize clinical judgment and industry guidelines while participating in telephonic hearings to present arguments for reversing Medicare denials in a remote setting.

Key responsibilities

• Prepare professional clinical appeals in response to managed care, governmental, or RAC denials for hospital clients
• Utilize industry guidelines and best practices to review medical records and write appeals
• Participate in telephonic Administrative Law Judge Hearings and present oral arguments

Required qualifications

• Bachelor of Science degree in Nursing
• Current state RN licensure
• At least 5 years of clinical experience in an acute care setting
• At least 3 years of case management, concurrent review, or utilization management experience
• Proficiency in medical record review