Florida Licensed Appeals Nurse

A company is looking for an Appeals Nurse to facilitate medical necessity appeals and denials. Key Responsibilities Review clinical data to determine claim payment based on company policies and NCQA guidelines Prepare case reviews for the Medical Director and generate appeal resolution communications Maintain the appeals process within NCQA timeframes and assist with policy revisions Required Qualifications LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience Proficient with Microsoft Office applications Experience with utilization or appeals review preferred Knowledge of InterQual criteria preferred Current RN or LPN license

Apr 8, 2025 - 19:47

A company is looking for an Appeals Nurse to facilitate medical necessity appeals and denials. Key Responsibilities Review clinical data to determine claim payment based on company policies and NCQA guidelines Prepare case reviews for the Medical Director and generate appeal resolution communications Maintain the appeals process within NCQA timeframes and assist with policy revisions Required Qualifications LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience Proficient with Microsoft Office applications Experience with utilization or appeals review preferred Knowledge of InterQual criteria preferred Current RN or LPN license