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State Licensed Clinical Review Clinician
A company is looking for a Clinical Review Clinician - Appeals. Key Responsibilities Perform clinical reviews to resolve and process appeals by analyzing medical records and clinical data Prepare case reviews for Medical Directors and ensure timely processing of appeals in accordance with standards Communicate with members, providers, and other departments regarding appeal requests and generate resolution communications Required Qualifications Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing 2 - 4 years of related experience in appeals, denials, and utilization management Active nursing license or relevant clinical licensure (LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist) Knowledge of NCQA, Medicare, and Medicaid regulations preferred Familiarity with utilization management processes preferred
A company is looking for a Clinical Review Clinician - Appeals.
Key Responsibilities
Perform clinical reviews to resolve and process appeals by analyzing medical records and clinical data
Prepare case reviews for Medical Directors and ensure timely processing of appeals in accordance with standards
Communicate with members, providers, and other departments regarding appeal requests and generate resolution communications
Required Qualifications
Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
2 - 4 years of related experience in appeals, denials, and utilization management
Active nursing license or relevant clinical licensure (LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist)
Knowledge of NCQA, Medicare, and Medicaid regulations preferred
Familiarity with utilization management processes preferred
