California RN Clinical Review Clinician

A company is looking for an RN Clinical Review Clinician - Appeals. Key Responsibilities Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data Ensures timely review and response to appeals in compliance with State, Federal, and NCQA standards Communicates with members, providers, and departments regarding appeal requests and generates resolution reports Required Qualifications Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing 2 - 4 years of related experience CA RN Licensure required Knowledge of NCQA, Medicare, and Medicaid regulations preferred Knowledge of utilization management processes preferred

Apr 2, 2025 - 16:46

A company is looking for an RN Clinical Review Clinician - Appeals. Key Responsibilities Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data Ensures timely review and response to appeals in compliance with State, Federal, and NCQA standards Communicates with members, providers, and departments regarding appeal requests and generates resolution reports Required Qualifications Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing 2 - 4 years of related experience CA RN Licensure required Knowledge of NCQA, Medicare, and Medicaid regulations preferred Knowledge of utilization management processes preferred