State Licensed Clinical Review Nurse

Job Summary

To support the Ambetter & MI Medicaid Market, the full-time remote State Licensed Clinical Review Nurse in Appeals will perform clinical reviews to resolve and process appeals by analyzing medical records and clinical data to determine medical necessity in accordance with policies and standards.

Key responsibilities

• Prepares case reviews for Medical Directors by researching appeals and analyzing applicable criteria
• Ensures timely review and processing of appeals in compliance with State, Federal, and NCQA standards
• Communicates with members, providers, and other departments regarding appeals requests and resolutions

Required qualifications

• Degree from an Accredited School of Nursing or a Master's degree in Behavioral Health or Social Work
• 2 - 4 years of related experience, preferably in appeals or utilization management
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• State Licensure as an LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist required
• Proficiency in using clinical decision-making tools such as InterQual