RN Clinical Appeals Nurse

A company is looking for a Clinical Appeals Nurse, responsible for investigating and evaluating member and provider disputes regarding adverse determinations and coverage decisions. Key Responsibilities: Investigate and evaluate written appeals and reconsideration requests from various stakeholders Respond with clinically informed and regulatory-compliant decisions through detailed correspondence Compile clinical records and communicate appeal outcomes to members and providers in a timely manner Qualifications: High School Diploma or equivalent required; BSN or MSN strongly preferred Minimum 2 years of direct clinical experience in a medical-surgical or acute care setting, or 3 years in mental health settings Preferred experience includes at least 2 years in Utilization Management, Case Management, or Medical Review Required RN - Registered Nurse, State Licensure and/or Compact State Licensure Preferred certifications include CCM - Certified Case Manager and LNCC - Legal Nurse Consultant Certified

May 19, 2025 - 06:50

A company is looking for a Clinical Appeals Nurse, responsible for investigating and evaluating member and provider disputes regarding adverse determinations and coverage decisions. Key Responsibilities: Investigate and evaluate written appeals and reconsideration requests from various stakeholders Respond with clinically informed and regulatory-compliant decisions through detailed correspondence Compile clinical records and communicate appeal outcomes to members and providers in a timely manner Qualifications: High School Diploma or equivalent required; BSN or MSN strongly preferred Minimum 2 years of direct clinical experience in a medical-surgical or acute care setting, or 3 years in mental health settings Preferred experience includes at least 2 years in Utilization Management, Case Management, or Medical Review Required RN - Registered Nurse, State Licensure and/or Compact State Licensure Preferred certifications include CCM - Certified Case Manager and LNCC - Legal Nurse Consultant Certified