State Licensed Clinical Appeals RN

Job Summary

State Licensed Clinical Appeals RN, this full-time position involves conducting medical necessity reviews, performing retrospective medical record reviews, and managing clinical appeals for hospital encounters.

Key Responsibilities

• Conduct pre and post service medical necessity reviews using evidence-based criteria
• Prepare, submit, and track clinical appeals while collaborating with various healthcare teams
• Track and report denial and appeal outcomes, identifying trends for process improvement

Required Qualifications, Training, and Education

• Current unrestricted Registered Nurse license in the state of residence
• University Degree with a minimum of 4-6 years of acute care clinical experience
• Prior experience in clinical denials, utilization review, case management, or appeals
• Experience with InterQual and/or Milliman Care Guidelines preferred
• Strong knowledge of hospital revenue cycle workflows and payer regulations