State Licensed Clinical Nurse Specialist
Job Summary
Serving as a clinical subject matter expert, the full-time State Licensed Clinical Nurse Specialist will perform complex clinical reviews, manage appeals and claims-related cases, and collaborate across various operational areas in a remote setting.
Key responsibilities
- Conduct complex clinical reviews for pre-service, concurrent, and post-service cases requiring advanced nursing judgment
- Review and provide recommendations for standard and expedited appeals, ensuring compliance with medical necessity criteria and regulatory requirements
- Analyze trends in clinical escalations and claims, partnering with cross-functional teams to identify issues and recommend process improvements
Required qualifications
- Registered Nurse (RN) with a current, unrestricted license
- Minimum of 5 years of clinical nursing experience, including complex medical record reviews
- At least 2 years of utilization management or closely related managed-care experience
- Working knowledge of CMS guidelines and medical necessity review processes
- Experience with appeals, claims review, and clinical escalations
Complete Job Description
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